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THE NEW SYDENHAM
SOCIETY.

INSTITUTED MDCCCLVIII.

VOLUME LXVII.

D\ego

of

San

THE

COLLECTED WOEKS

DR. p. M. LATHAM,

MEMOIR BY SIR THOMAS WATSON, BART., M.D.

EDITED FOR THE SOCIETY BT

EOBEET MAETIN, M.D., Cantab.,

FELLOW OP THE KOTAL COLLEGE OP PHYSICIANS; LATE PHTSICLMf TO
ST. BAETHOLOMEW'S HOSPITAL.

IN TWO VOLUMES.
VOL. I.

THE NEW SYDENHAM SOCIETY,
LONDON.

MDCCCLXXVJ.

PEINTED BY W. CLINKSKEL, AT EA6TCHEAP PEIKTIKG WOEKa.

EDITOR'S PEEFACE.

"When first asked by the Council of tlie Sydenham Society
whether I would undertake to edit a reprint of the writings of
Dr. Latham, I hesitated, somewhat, before giving an affirma-
tive answer.

I hesitated because I was told, in the courteous letter con-
veying the wishes of the Council, that although they " did not
purpose, in the least, to try to modernize the work, or to
bring the information up to the present day," still, that it ^cas
intended the editor should " annotate as might seem needful to
prevent misunderstanding."

But my doubting did not last long. For a very little re-
flection, a few words of conversation with the Secretary of the
Society, and my recollection of Dr. Latham's own comments
upon commentators (see his preface to this volume) soon con-
vinced me that I might safely undertake the work without
endangering its success.

It seemed to me that whatever the additions which might,
perhaps legitimately, be made as supplementary to the author's
text, and whatever the different interpretations which might,
with our present knowledge, be given to some of his subject-
matter, still, that the " sense of the author " was always
"clear beyond dispute," and would only too probably become
unintelligible when encumbered with the help of so-called " ex-
planations." A simple reprint appeared to be all that was
desirable; and in this case my duties would begin, and my
responsibilities would end, with a faithful revision of the press.

In truth it would be hardly possible to add much, of abso-
lutely certain knowledge, to the grand broad outline which Dr.
Latham drew of heart disease — its general symptoms and its
physical signs. And surely the attempt to fill in that outline
with some comparatively minute and unimportant detail, would

yi editor's preface.

be as presumptuous, and out of place, as would be tbe en-
deavo"ur, on the part of some artist " prentice-hand," to sup-
plement in like manner the simple grandeur of a Raphael
cartoon !

Moreover, in the preface to his first series of lectures Dr.
Latham writes : " Auscultation " (he is now speaking of the
limgs) " is capable, I have thought, of being greatly simplified
for practical purposes. At all events, unless it be so, it can
never be successfully taught ; the knowledge derived from it
must be confined to a few physicians of hospitals, and the pro-
fession at large can never expect much benefit from its use.

" Whether I have succeeded in accomplishing what I think
so desirable, and have cleared auscultation of its mystery in any
degree, others must judge. But thus much I can safely say,
that the intelligent student, by attending to the few character-
istic sounds which I have pointed out, and taking pains to
understand their import, and guarding himself against over-
refinement, is able in a few weeks to discern the leading truths
connected with auscultation, and in a few months to use it
and trust it as his safest guide in the diagnosis of pulmonary
diseases.

" Such are the objects which these lectures have in view.
They do not pretend to teach the clinical student any single thing
peremptorily or dogmatically, but only to furnish him with
certain aids and assistances by which he may be better able to
teach himself."

Again, in the preface to this volume on diseases of the
heart he says : " The clinical diagnosis of diseases of the heart
owes all the higher degrees of certainty to which it has been
carried in our own times, entirely to auscultatory signs.
Accordingly it became necessary for me to give some accoimt of
their theory and their uses, and I have desired to do it as simply
as possible. Their perfect theory, however, lies deeper than
our present knowledge, and all the uses of which they are
capable must wait to be developed by more and more multiplied
observations of the sick.

" But already there is some true light in which these signs
may be regarded ; and already there is a large extent to which
they may be followed and trusted as the faithful exponents of
diseases of the heart. And although on this subject doubtless

EDITOR^S PREFACE. vii

there has been error and mistake, and a good deal has been
taken for more certain, and something for less certain, than it
really is, so that we have both to learn and to unlearn, yet
enough is already known to make the diagnosis of diseases of
the heart hardly anything else than a just appreciation of their
auscultatory signs."

With such language before me, with protests so earnest and
so potent against the dangers of over-refinement, I cannot but
think that any poor foot-note of mine, upon, for instance,
"presystolic murmurs," would be eminently ill-timed.

Sir Thomas Watson, in the touching biographical notice of
Dr. Latham which he wrote for the St. Bartholomew's Hospital
Hoports of 1875 (with a reproduction of which he allows the
enrichment of this volume), has done ample justice to the powers
of our author's mind, and to the eloquence and grace of his
diction. But I may be permitted perhaps, very briefly, to
allude to some of the more especial characteristics of his
writing. I would put first of all the breadth of view with
which he contemplates every subject he approaches, and with
which he includes all the side issues in connection with it.

He is discussing, for instance, the question of albuminuria —
" the greatest single pathological fact disclosed during the pre-
sent century " — and after alluding to the many diseased con-
ditions with which this fact is coincident, and after entertaining
the question of the blood being " the common agency by which
these multitudinous eifects are brought to pass," he goes on
to speak of the prior causes leading up to these efiects, to be
found, he says, in " the habits, the necessities, the misfortunes,
and the vices of men," and so arrives presently to touch upon
one of the burning questions of to-day, intemperance, and the
moral obligation of the physician to aid in the prevention of
what is so often incurable.

Again, he is speaking of disease as a great physiological
teacher, and straightway he alludes — and somewhat strongly
too, as might be expected from one of his exquisitely sensitive
nature — to the subject of vivisection.

Let it not be supposed, for one moment, that he absolutely
condemns the practice of experimenting upon living animals.
He knew far too well how greatly indebted was his profession
to a succession of experimenters, from a Harvey to a Hope, for

viii editor's preface.

all its certain knowledge of tlie circulation, to allow of his
denying the opportunity for well-considered investigations. It
was rather with the wish of elevating the experiments insti-
tuted by disease, and of contrasting their perfection with the
imperfection of all human attempts to imitate them, that he
expresses himself as he does, and gives a somewhat lukewarm
approval.

How greatly ought we to respect him for his honesty, his
fearlessness, his candid impartiality, his readiness to admit a
difficulty, to suggest a doubt, to confess his ignorance.

Take, for example, his mode of handling the subject of the
treatment of acute rheumatism with all its complications in
Lecture X. How thoroughly and conscientiously has he gone
through all the varieties of treatment, by bleeding, by opium,
by calomel, by colchicum, b}'' purgatives ; how honestly has he
contemplated the possibility of the disease wearing itseK out on
the do-nothing treatment ; and how logically does he sum up
in favour of what he calls the " compoimd method " which
"while it works with all the means which have been recommended,
stops short of what is harsh and excessive in their use, and yet
compasses with more certainty the successful result."

And here I shall venture, in anticipation of the objections
which may be made to what has been, and what will be called
"Dr. Latham's old-fashioned notions of treatment," to give at
length from one of his later essays (presently to be reprinted, I
trust, together with others of the same date) his own more
matured views on this matter of " old-fashioned treatment," of
new-fashioned treatment, and of no treatment at all — preferring,
as Sir Thomas "Watson says, to make him " his own eloquent
expositor," rather than run the risk of failing to do him justice
by any imperfect summary of mine.

" On my first entrance into mj profession, and for some
time afterwards, nothing was less intelligible to me than the
writings of our great physician. All his discoursings about
epidemic constitutions, and stationary fevers, and intercurrent
diseases, and the same diseases needing different treatments
from time to time, were to me dark and mysterious. And just
the same, I am persuaded, is the case with every man who
studies medicine ; and the more so, the more he finds himself
thus early in the presence of real disease, and in the society of

editor's preface.

IX

those who, like himself, are daily watching it, and ministering
to it, and comparing notes about it. For then the mind is at
its freshest and its best, and is most apt for observation. It
holds strongly to its own conclusions : and why should it not ?
It takes for absolute truth what has already come to it authen-
ticated by a hundred instances : and why should it not ? It is
not yet upon the look-out for what may gainsay or invalidate
its own well- observed facts concerning diseases and remedies :
why should it ? Tell, therefore, the student, and the physician
of a few years' standing, that there is something more in diseases,
and in the effects of remedies upon them, than can be seen and
known from any number of individual patients during any
given period of time, and he will neither understand j^ou nor
believe you. Yet there is something more, nevertheless ; and
physicians at length come to own it.

" Choose almost any febrile disease you please, and question
the experience of honest and well-informed physicians about it,
and what it was, and how it was best treated at their own time
and place of observation ; and you will find them tolerably well
agreed. But take this experience and agreement of theirs to
determine its nature absolutely, and fix the canon of its treat-
ment for all places and all times, and you will run into a great
practical delusion. Still, a man must have lived long enough
to see many phases of medical practice, and been himself
engaged in it all the while, before he can be in a condition
freely to acknowledge what is here implied.

" Take pneumonia. It has been treated by bleeding, and got
well. It has been treated by brandy, and got well. It has been
left to itself, and got well. And the bleeders, the brandy-
givers, and the doers of nothing at all, respectively, have had a
vast deal to say for themselves and against their rivals. And
which of them are to be our guides and masters in the treat-
ment of pneumonia ? None of them for a single day, much less
for always. Besides, the treatment of pneumonia happens just
now to be a matter of high controversy ; and from controversy
often comes exaggeration. And exaggeration often does the
work of falsehood unawares. Therefore I would willingly have
chosen some other instance, but that I wanted such internal
febrile disease for illustrating my purpose, as, whenever it
exists, declares itself infallibly. And since erysipelas well

X ' editor's peeface.

served my purpose, because all about it was plain and unmis-
takeable to the eye, so now pneumonia will do the same, because,
of internal diseases, it and all about it are best ascertained by
tbe ear.

" Now, we have the best testimony which the ear can afford
to the fact that jjneumonia has gone through all its processes of
disease and reparation, now advancing, now receding, until the
lungs have finally recovered the conditions of health, when it
had received no formal medical treatment whatever. Again,
we have the sure witness of the ear to the same fact, when the
pneumonia had been treated by brandy ; and yet again to the
same fact when it had been treated by venesection.

" Here the means (for even the doing of nothing may be now
deemed to exercise a positive influence), the means, I say, and
the end, are things so obvious, and are found so closely follow-
ing each other, that it is impossible not to put down their
sequence to the account of natural connexion. And this being
the case, and there being such vast odds between doing nothing,
giving brandy, and drawing blood, there is no wonder, if the
current of a man's experience had run generally in favour of
any one of the three, that he should hold one to be absolutely
and always right, and the other two absolutely and always
wrong.

" JSTo wonder, indeed. But then practical medicine is unlike
all other things in the world. It has its own conditions, and
they prohibit all such summary conclusions as these. Let a
man use his own experience as best he can for the present ; but
let him not, u2:)on the strength of it, rebid^e the experience of
all past times, and dictate to the experience of all future ; for if
he live long enough, nothing is more likely than that he may
find himself fallen under his own reproof, and inconveniently
confronted by his own maxims. From having been a bleeder
he may become a stimulator, or a passive looker-on in cases of
pneumonia. He may find himself interchangeably all three in
the course of thirty years.

" And what is the explanation of all this ? People not over
well disposed towards us and our profession (and there are
many such) find a sufiicient key to the whole matter in the
caprice of medical men, and they take this key of theirs and
turn the lock, and bar the door against all further question !

EDITORS PREFACE. xi

* It is neither more nor less,' say tlicy, ' tlian tlic caprice of
physicians ; so let us have done with it and them.'

" But let the world think o£ us as it pleases, there is a rational
practice of medicine nevertheless, and let medical men them-
selves still be right and wrong by turns, seeing clearly and doing
successfully what is at present to be seen and done, yet mis-
taking the same for something more sure and permanent than it
really is ; finding (as it were) a fragment of truth, and learning
well what it will now bear, and now safely trusting their own
weight upon it, let them foolishly deem it a rock and build a
castle upon it. Whatever physicians may be, or the world may
think of them, there is, I say, a rational practice of medicine
nevertheless, and there are causes sufficient to explain its
greatest anomalies."

He then goes on to glance cursorily at what these causes
are : — an individual man's constitution ; the external agencies,
good and bad, by which he (or a community of individuals) is
surrounded, and by which his " vital being " is aifected ; and
lastly, and more fully, he touches upon the question of " Epi-
demic Constitution " as also influencing and modifying treatment
at difierent times.

And here again I am tempted, especially just now, and in
view of (may it not be asserted?) a change of treatment
steadily gaining ground — whether caused by a change in the
" Epidemic Constitution " of these later two or three years, or
whether by a better, a more just, estimate of the powers, and
of the weakness, of alcoholic stimulants I dare not say — I am
tempted to give one more extract from the same fertile source.

"All general terms in use among physicians had need to be
jealously watched. Even strength and weakness, simple and
innocent as they look, have by turns been the marring of us.
The terms themselves cannot be dispensed with ; and so long
as they truly represent (as they always ought) an aggregate of
things real, and verifiable in their details, they serve a useful
purpose. But, failing this, they become pernicious abstrac-
tions. In my time Medicine has been going through a specu-
lative crisis of two opposite kinds by turns ; and strength (so-
called) has ruled the one, and weakness the other. Beyond all
question, during its critical ascendancy, abstract strength cost
the world many lives by its practice of blood-letting; and

xii EDITOR'S FREFACE.

abstract weakness, in its turn, has cost the world many also by
its practice of brandy-giving. I have not statistics to show
with exactness which of the two has levied the larger mortal
tax upon mankind. My impression is that the bad pre-eminence
belongs to the latter."

Finally, I would have the readers of this volume ponder well
over the* subjoined pregnant paragraph of Sir Thomas Watson,
writing of Dr. Latham's account of the Millbank Penitentiary
epidemic; I would have them study carefully Lect. XIV., which
is devoted to a consideration of the antiphlogistic and reparatory
powers of mercury as illustrated by its efi'ects in iritis ; and I
would have them read once more Sir James Paget's sectional
address in surgery, given at the meeting of the British Medical
Association at Norwich, in 1874, before they come to any
(foregone) conclusion upon so-called " old-fashioned treatment."

* " One absolute fact which it records is well worth remembrance in the
present sceptical mood of some among us as to the value and the virtue of
drugs. 'I'he disease, whatever may have been its real nature and origin,
was at length, after defying almost every other conceivable method of
rational treatment, at once arrested in every instance in which mercury
was given and pushed to the extent of producing its specific effect upon the
gums."

Queen Anne Street,
Aurjust, 1876.

in iMtmon'am.

DE. PETER MEKE LATHAM.'

BY

SIR THOMAS WATSON, Bart.

Dr. Peter Mere Latham was the second of tlie three
sons of Dr. John Latham and of Mary, the daughter
of the Rev. Peter Mere, Vicar of Prestbury, in
Cheshire. Besides their relation of consanguinity,
the quahties and fortunes of these two men were in
many points so interwoven and similar, that any
memoir of the son, in these pages especially, might
justly be deemed defective, which did not include
some record, however brief, of the father also. Both
of them were eminent London physicians in their
day ; both held in succession the office of physician,
first to the Middlesex and then to this great hospital ;
both were appointed Physicians Extraordinary to the
reigning Sovereign; of both of them it may confi-
dently be added that they were men of blameless life
and exemplary character. Of the father I had some
partial knowledge during my early residence in Lon-

* Eeprlnted, by permission, from St. Bartholomew's Hospital
Eeports, vol. xi.

XIV IN MEMORIAM.

(Ion; the son, during the whole of my professional
life, was my most intimate and familiar friend.

Dr. John Latham then, was born on the 29th of
December, 1761, at Gawsworth, in Cheshire, in the
house of his great-uncle, the Eev. William Hall, then
rector of that parish. He received his early education
in the country. In 1 778 he was entered at Brazenose
College, Oxford; and in 1788 he was created M.D.
of that University. In that year also he settled in
London, after having practised for two brief periods
at Manchester and Oxford. He became a Fellow of
the London College of Physicians in 1789 ; and in
the same year was elected physician to the Middlesex
Hospital. That office he resigned in 1792, upon his
election as physician to St. Bartholomew's. From
1813 to 1819, inclusive, he was President of the Col-
lege of Physicians. His first London residence was
in Fenchurch Buildings, where his son, Peter Mere,
was born. In 1795 he moved to the house in Bedford
Eow, which the well-known Dr. Reynolds then quitted
for Bedford Square. Here he practised his profession
with immense repute and success, until, at the early
age of forty-six, his health utterly broke down under
excessive and incessant toil, and he was compelled to
retire into the country, as it was thought, to die. He
went to an estate which he had purchased at Sandbach
in Cheshire ; and there, under the beneficent influence
of mental rest and pure air, recovered completely, so
as to be able to return to London, where he lived, in
Harley Street, for twenty years, in better health and
more moderate practice than before. He finally left

IN MEMORIAM. xv

London for Iiis scat, Bradwoll Hall, in 1829, and died
there in 1843, from the effects of stone in the bladder,
in the eighty-second year of his age.

What I remember of him is chiefly that he was
very hospitable ; kind and helpful to young j^^^y^i"
cians ; courteous, of winning manners and address ;
and highly esteemed and popular, both with his
patients and with his medical brethren. It has been
written of him by the truthful pen of that son who is
the chief subject of this memoir, that ''he was
singularly temperate when temperance was hardly
yet thought to be a virtue, he was most pure in life
and conversation when to have been otherwise would
have provoked no censure, and he was not ashamed
to be religious when religion had yet no recommenda-
tion or countenance from the world."

His son, Peter Mere, was born on the first day of
July, 1789. He was a very delicate child, and was
sent for the first rudiments of his education to Sand-
bach, where he resided with his paternal grand-
mother, and attended the free school of that town, ol
which the clergyman of the parish, the Rev. Charles
Lockett, was master. About a year later, in 1796 or
1797, he was transferred to the Grammar School of
Macclesfield, at that time under the charge of Mr.
Davis, the husl^and of his mother's sister. There he
remained until he began to reside at Brazenose
College in 1807. He took his M.D. degree at Oxford
in 1818, and in the same year became a Fellow of the

xvi IN MEMORIAM.

College of Physicians. He had come from Oxford to
study medicine at this hospital in 1810. In 1815 he
was elected physician to the Middlesex Hospital ; and
to St. Bartholomew's in 1824. Beaten first from this
post, and at length from practice, by persistent and
severe attacks of asthma, he withdrew in 1865 to
Torquay, where he died on the 20th of last July,
having just entered his eighty-seventh year.

That he lived so long was a marvel to all who
were aware of his bodily constitution. I have said
that in childhood his health was delicate. In mature
life, when he was living in London, besides a slight
twist in his spine, which tilted one shoulder a little
upwards, his lungs were known to be extensively
emphysematous, and his paroxysms of asthma by
night were so extremely violent and exhausting, that
many times he fully expected to die before the morn-
ing. Had he remained longer in London it is almost
certain that some one of such paroxysms would have
been fatal.

He had twice been married ; first to Diana
Clarissa Chetwynd Stapleton, grand-daughter of Lord
Chetwynd ; she died in 1825, within a year of their
marriage; and secondly, to Grace Mary Chambers,
third daughter of Commander David Chambers, R.N.
By her he had four children, who all survive him ;
two sons, both married, Weyland Mere and Philip
Arderne; and two unmarried daughters, Diana
Frances and Mary Grace, by whom, together with
Miss Gooch, who lived with them at Torquay, the
daughter of his early friend, Dr. Gooch, he was

IN MKMOUIAM. Xvii

assiduously and tenderly nursed throughout the whole
of liis declining- years.

As a school-boy he is said to have been idle, and a
hater of Latin and Greek. If so, his tastes and habits
must have altered greatly in after life; for in 1809,
having made two previous failures, he gained the
undergraduate's prize for Latin verse at Oxford. The
subject was " Corinth." It is worthy of mention, if
only in proof that the teaching at Macclesfield had
been sound and effective, that his elder brother John
and his younger brother Henry, who also were trained
in that school, achieved, both of them, while at Braze-
nose, a similar distinction. One of the unsuccessful
competitors for the same prize in 1812, when Henry
obtained it, was Arnold, afterwards the famous head-
master of Rugby. I was told also by a profound classi-
cal scholar, who was possessed with the strange curiosity
to read all the printed Harveian Orations, that sub-
sequently to the date of Sir George Baker's, that by
Dr. P. M. Latham was one of the very few the Latinity
of which he could praise. Indeed, his English style
bespoke a master of Latin ; slightly quaint, perhaps,
it might sometimes be, but stately withal, and always
clear, vigorous, and exact.

Of the facility in writing Latin verse acquired by
the eldest and the youngest of the three brothers
ample evidence exists in two pleasing little volumes,
the one by John Latham, D.C.L., unpublished, con-
taining '■'■ English and Latin poems, original and
translated ;" the other, published in 1864, by the Rev.
Henry Latham, entitled ''Sertum Shaksperianum, sub-
nexis aliquot aliunde excerptis floribus."

h

xviii IN MEMOEIAM.

The poems of the eldest brother — poems of great
beauty, humour, and tenderness — were composed
under the sore disadvantage of almost total blindness.
At the early age of twenty his hopes and promise of
.success as a barrister were destroyed by a severe attack
of ophthalmia, which left him with only enough of
sight to guide his steps, but for ever afterwards unable
to read a word of writing or of print.

When Dr. Latham became a student at this hos-
pital, the three physicians were Doctors Roberts,
Powell, and Haworth. It was the custom of that time
— before clinical clerks had been heard of in London
— for the senior students, especially those who came
from the Universities, to attach themselves to some
one of the physicians, to watch his practice, and in a
certain sense and degree to superintend his patients.
Dr. Latham so waited upon those of Dr. Haworth.
But, anxious to make his study and knowledge of
disease as comprehensive as was possible, and to
familiarise himself with the puzzling diseases of the
skin among the rest, he began, during this period, to
attend also the practice of the celebrated Dr. Bateman
at the Carey Street Disj^ensary. There, in 1813, he
first met the late still more celebrated Dr. Richard
Bright, and contracted with him a life-long friendship.
The winter of the end of that year and the beginning
of 1814 was a very remarkable one. The Thames
Avas frozen over, and a fair was held uj^on the ice.
The amount of misery, destitution, and disease pro-
duced by this long inclemency of weather was
enormous; the duties of the Disj^ensary physicians

IN MEMORIAM. XlX

increased beyond their strength, and were in part
delegated to tlieso two young students ; who thus first
became actual practisers of their future calling, in the
highest and lowest garrets and cellars of St. Giles's.

Among Dr. Latham's fellow-students and com-
2)anions at St. Bartholomew's were Haviland, after-
wards Regius Professor of Physic at Cambridge ;
Monro from Oxford; William Lawrence, already
Demonstrator of Anatomy, Henry Earle, and Edward
Stanley, all three surgeons to the hospital in the future;
Hodgson, subsequently famous as ''of Birmingham ; "
and James "of Exeter." He found the stimulating
plan in vogue, by bark and wine, and the mortality
great. A controversy was raging there about the
A'alue and propriety of blood-letting in fevers. Upon
his election, at the age of twenty-six, to be j)hysician
to the Middlesex, he resolved to shut \ip his books, and
to try and judge for himself. He was soon led to use
bleeding, not from any doctrine then prevalent, but
from his own observation. His work, in his new and
responsible position, was carried on with uncommon
diligence and energy. Living, as yet unmarried, in
Gower Street, and dining usually with his father in
Harley Street, it was his custom on his way home at
night to turn in at the Middlesex to see some of his
patients, especially his fever patients ; and he generally
did something for them, — gave, j^erhaps, a few droits
of laudanum to one, had the shirt taken off and the
body sponged of another, or the feet only sponged
with warm water. The result of this kind of special,
minute, and unremitting care was a notably smaller

XX IN MEMOKIAM.

amouut of mortality among his fever cases than among
those of another of the physicians.

Towards tlie close of his incumbency at the Middle-
sex Hospital— from March, 1823, to May, 1824— Dr.
Latham was employed, in conjunction with Dr. Rogct,
in investigating the nature and source of an obscure
epidemic disorder then prevailing in the General
Penitentiary at Millbank. In 1825 he j)ublished an
account of this inquiry — his first professional writing.

The book is pregnant with evidence of acute and
patient research, and of clear cogent reasoning. One
absolute fact which it records is well worth remem-
brance in the present sceptical mood of some among
us as to the value and the virtue of drugs. The
disease, whatever may have been its real nature and
origin, was at length, after defying almost every other
conceivable method of rational treatment, at once
arrested in every instance in which mercury was given,
and pushed to the extent of jDroducing its well-known
specific effect upon the gums.

For four years, dating from the autumn of 1816,
Dr. Latham delivered annually, in association with his
colleague Dr. Southey, two courses of lectures on the
Practice of Physic. The manuscript of these lectures
is still in existence. Tied up with it are the following
notices written by his own hand : —

" In looking over these voluminous papers after the lapse of
forty-nine years (viz. in my seventy-sixth year), I am amazed at
the pains, and care, and time I must have bestowed in putting them
together. I would have committed them to the flames — but I shrank
from a deed which was painful. So I again locked them up. — .Tune
1, 1865. P. M. Latham."

IN MEMOKIAM. Xxi

And again, later —

" NoAv, iu my eighty-fifth year, I encounter again my century of
Medical Lectures, with their scrap of paper tied round. I was
again tender towards my own offspring, and again shut them up and
locked the box.— Nov. 28, 1873. P. M. Latham."

Dr. Latham's first project, in the publishing way,
after the commencement of his work at St. Bartholo-
mew's, proved abortive. For ten years he had been
collecting and arranging materials for, and was about
to put forth, a book on Continued Fever. His clinical
clerks had been chosen with care, his case-books had,
by them, been regularly and accurately kept, and their
contents analysed and digested by himself. It ap-
2)eared that he had bled from the arm one in every
four of his fever patients, and leeched nearly all of
them, with a mortality of seven in the hundred. All
that died of the fever were found to have ulcerated
bowels. Then, suddenly — it was just after the first
invasion of the cholera — a startling change took place.
He no longer dared to bleed any of his fever patients ;
on the contrary, he was obliged to uphold them.
Their skins were mottled with an eruption, and often
spotted with petechise. So numerous became the
deaths, that time could not be found for examining
many of the dead bodies. I think he told me that the
mortality was doubled.

We know now the solution of this perplexing
change. The fever which he had been so long watch-
ing was typhoid, or enteric fever ; the new cases be-
longed to a severe epidemic of typhus. At that time
the distinction between these specifically difi'erent

xxii IN MEMORIAM.

forms of continued fever had not been recognised.
His intended book never saw tlie light.

When he had been eleven years i^hysician to St.
Bartholomew's, he began to give those admirable
'' Lectm-es on subjects connected with Clinical Medi-
cine," of which the first were published in a single
small volume in 1836, and which marked an era in
the clinical teaching of this country. Among their
incidental good effects was that of commending to our
acceptance and study the even then novel theory and
practice of auscultation, by substituting for the techni-
cal terminology of Laennec, words and phrases more
simple and familiar to the English ear. The conscien-
tious discharge of all his hospital obligations was very
remarkable. These lectures were given at an early
hour, for a special reason, which may best be stated in
his own words : —

"I have desired," lie says, "to meet the students before their
minds were pre-occupied with other things ; that among the inter-
fering demands of other objects which arise in the course of the
day, they should not have to catch a moment for that which I con-
sider is the greatest of all — to steal a brief interval between lecture
and lecture, and give it to that to Avhich all lectures, and all the
knowledge conveyed in all lectures, is but subsidiary and subordi-
nate. I would not thank them for such an irksome, wearied atten-
tion ; I want them when their minds are fresh ; and, therefore, I
have always given myself to them when mine is fresh."

As he always gave these lectures, so also Dr.
Latham visited his patients — in the early morning.
One result of this was, that very few of the students,
rarely more than ten, went round the wards with him;
but these '' few" were also ''fit; " they were always
the most studious men of their time, and among

IN MEMOKIAM. xxiii

them were many of tlio most (listinguishcd of liis
.successors.

The spirit in which ho fidfilled his functions as a
teacher may also be ])cst shown by some furtlicr
quotation from this little volume. After statinj^ that
the disordered human body must be the study and the
continual care of his hearers, he goes on : —

" And is it possible to feel an iaterest in all this ? Ay, indeed
it is ; a greater, far greater interest than ever painter or sculptor
took in the .form and beauties of its health.

"Whence comes this interest? At first, perhaps, it seldom
comes naturally : a mere sense of duty must engender it ; and still,
for a while, a mere sense of duty must keep it alive. Presently the
quick, curious, restless spirit of science enlivens it ; and then it
becomes an excitement and a pleasure, and then the deliberate
choice of the mind.

" When the interest of attending the sick has reached this point,
there arises from it, or has already arisen, a ready discernment of
diseases, with a skill in the use of remedies. And the skill may
exalt the interest, and the interest may improve the skill, until, in
process of time, experience forms the consummate practitioner.

" But does the interest of attending the sick necessarily stop
here ? The question may seem strange. If it has led to the readiest
discernment and the highest skill, and formed the consummate
practitioner, why need it go further ?

" But what if humanity shall warm it ? Then this interest, this
excitement, this intellectual pleasure, is exalted into a principle, and
invested with a moral motive, and passes into the heart. What if
it be carried still further ? What if religion should animate it ?
Why, then, happy indeed is that man whose mind, whose moral
nature, and whose spiritual being, are all harmoniously engaged in
the daily business of his life ; with whom the same act has become
his own happiness, a dispensation of mercy to his fellow-creatures
and a worship of God."

That this happiness was the portion of the lecturer
himself, we may hold the perfect assurance.

Of the method of his clinical teachins: I must still

XXIV IN MEMOKIAM.

make himself tlie eloquent expositor. He lielj)S the
class to learn for themselves : —

"It is your present duty to exercise your observation carefully
and unremittingly ; and it is my present duty to point out tlie fittest
objects, and place them in the light in which they can be most
profitably seen.

" If ever the desire to view the beauties and sublimities of nature
has led you to ascend some lofty eminence, you have probably taken
with you one more familiar with the scene than yourselves, as a
guide ; but you have still trusted to your own eyes, and your own
feelings, to fill you with the delight of the prospect, and tell you what
to admire and Avonder at ; and you have required no more from the
guide than to point with his finger, and say, ' See here, and see there.'

" So, in entering this place, even this vast hospital, where there
is many a significant, many a wonderful thing, you shall take me
along with you, and I will be your guide. But it is by your own
eyes, and your own minds, and (may I add) by your own hearts,
that you must observe, and learn, and profit : I can only point to
the objects, and have little more to say than ' See here, and see there.' "

Under the same title as before, he published in
1845 two more volumes, full of exact observation and
valuable precepts, upon diseases of the heart. He had
resigned his office of j)hysician to St. Bartholomew's^
after seventeen years' tenure, in 1841. In the preface
to these lectures he writes : —

" I would have published other lectures, . . . but an enlarged
sphere of duty at the hospital and elsewhere engrossed all my time,
and impaired my health, and spoiled my good intention.

"The duty of physician to a great hospital, unless it can be made
easy by indifference to its highest obligations, is incompatible with
much care of personal health. Therefore, I relinquished my office at
St. Bartholomew's, and with it some of the best hopes I had of being
useful in my generation."

It is greatly to be regretted that both series of tliese
very excellent and instructive lectures are, and have
long been, out of print. '

IN MEMORIAM. XXV

At this period he stood in the foremost rank of
London physicians. I do not recollect when his cruel
malady lirst began seriously to hamper his practice.
For some time, however, before his resignation of the
hospital, a visit to the wards was almost sure to provoke
its access. Meanwhile he had never altogether laid
aside his pen. There are scattered — I might say
buried — in some of our medical newspapers, contribu-
tions from him well worthy of perusal and study. I
would refer to one paper in particular, on medical
education, in the first volume of the British Medical
Journal for 1864, because it contains an admirable
exhibition of the doctrine, always strenuously main-
tained by him, that we attempt to teach oui- students
too much science, to the displacement of practical
knowledge. " The practice of physic," I have heard
him say, "is jostled by quacks on the one side, and
by science on the other."

He was a slow, self-critical composer, fastidious in
settling his diction, and careful above all things that
it should clearly convey his meaning. With what
success that object was attained, they who may
chance to read this memoir have had some oppor-
tunities of judging.

When Dr. Latham quitted St. Bartholomew's, he
presented to the Library of the Hospital between fifty
and sixty volumes of his completed case-books; rich,
no doubt, with the fruit of his thoughtful and well-
trained observation. Some years afterwards he ex-
pressed his disappointment that they had not been
turned to any account. It was explained to him by

xxvi IN MEMORIAM.

his friend and successor, Sir George Burrows, that the
more correct classification which had been made of
continued fevers, and the remarkable change which
had come over the professional mind in respect of the
proper treatment of acute disease, and especially in
respect of the abstraction of blood, had made it very
difficult to bring his clinical records with advantage
before the public. Probably, besides these reasons,
there was also the want of an adequate and leisure-
gifted vates sacer. It cannot be doubted that those
volumes contain a mine of precious material, which
would amply repay the search of any one who, having
the requisite talent, might have the privilege of ex-
ploring it.

In the parallel which was drawn in a former part
of this memoir between the resj)ective careers of the
two Lathams, there was one notable breach. The
father was for several successive years President of
the College of Physicians ; that place of honour the
son never held. But this, as I believe, was owing to
a voluntary abstinence on his part. So long as the
President was appointed from among themselves by
that irresponsible and self-elected body of eight Fel-
lows, called '' The Elects," the burdens of the Presi-
dency might well be deemed by a toiling physician
to outweigh even its admitted dignity and advantages.
At any rate. Dr. Peter Mere declined to become an
Elect when chosen for that post in 1845, dreading, as
I know, lest by accepting it he should encounter,
as he almost certainly, sooner or later, would have
had to encounter, the cares and distractions, with the

IN MEMOKIAM. XXV ii

tlicn soiiicwliat dubious honour, of tlic Presidential
cliair.

"Settled by strong conviction in liis Christian faith,
Dr. Latham lived a life of unostentatious but habitual
piety." He was withal a charming companion, full of
various information, affluent in anecdote, with a keen
sense of fun and humour. With this was blended,
as is not uncommon, a quick susce2)tibility of pathetic
emotion. I have heard him read Miss Elliott's beau-
tiful hymn, ' Thy will be done,' with a choking voice
and tears in his eyes. His letters are treasures of
good sense, of lively and ejjigrammatic comments on
men and things, of shrewd and weighty reflections,
wise advice, and affectionate greetings.

I find myself writing in terms of unqualified praise;
but I am not conscious of wilful exaggeration. If ho
had faults — as doubtless he had — they refuse to live
in my memory. I must paint him as he was to me.
I have tried to let him portray himself.

One of the sterling and most prominent features
of his character was the same with that of which
Sir James Paget, in the ninth volume of these Trans-
actions, has drawn so touching a picture as exemplified
in his nephews, the two Ormerods. His conduct
throughout life was governed by an abiding and im-
perative sense of duty; and as a corollary of this
temper of mind must be reckoned his love and his
habits of order and method. The letters received by
liim and kept were all arranged in packets, and the
substance of each was noted on the envelope. Even
in his extreme feebleness at Torquay no book was

xxviu IN MEMORIAM.

ever suffered to be out of its place ; if no one was at
hand, he would rise from his chair with great exertion
and replace it. I am permitted by Miss Latham to
quote some words of her most interesting letter to
myself descriptive of his later condition :

" Every winter after his retirement to Torquay he suffered more
or less from asthma, but after the first four winters, and as his
bodily strength diminished, the attacks became less severe. During
summer, even up to 1874, he could drive out, walk a little in the
garden, and sit under the trees. It was a constant delight to him
to look upon the bay wdth the fishing-boats, the green fields with
the sheep, the garden with the work going on in it. He saw few
beyond his own family and his immediate friends. All that inter-
ested them interested him, and he watched the progress of his
friends and medical pupils with pleasure and pride. His books
were his chief companions. Wherever he was, in bed or in his
sitting-room, his Greek Testament, with Gresswell's Harmony and
Bengel's Commentary, were by his side, and were read and studied
over and over again. The Gospel of St. John was the Gospel that
he especially loved. He knew many chapters by heart in Greek,
and would repeat them to himself at night, or before he w^ent to
sleep. He did not speak much of holy things, but from words he
would let drop one could gather how far he entered into their
depth and truth. Arnold's sermons, Eeble's, and with others,
latterly those of Baldwin Brown, he never tired of having read to
him. Any biography of the men he had known, or any account of
the times in which he or his father had lived, interested him. And
he would often turn to the classics. Shakespeare and Milton w^ere
his favourite English poets. He had the articles of the Times read
to him daily, but his singularly pure, unprejudiced, clear mind
shrank from controversy. At last his reading was almost entirely
on sacred subjects. He shared all the little pleasures of those
about him, and was ready and anxious to heljj in any good work.

" By nature extremely sensitive, his patience and resignation
were very beautiful to witness. In his most acute attacks of asthma
no murmur ever escaped him, only touching aj^peals for strength to
bear what it pleased God to lay upon him. He often expressed
great thankfulness for all the blessings vouchsafed him, frequently
saying ' How happy I am.'

IN MEMORIAM. xxix

" His old age loas very happy and peaceful, a waiting for the
life to come.

" During tlie last few years he became gradually weaker, and the
attack of asthma that came on after Christmas, 1871, he never
thoroughly shook off. In April he rallied a little, but soon failed
again, and became almost helpless. When he was too weak to
listen to reading for more than a few minutes at a time, he was not
happy without those few minutes' reading from the Bible and the
favourite sermons. He talked to his children as well as breathlcss-
ness would permit, never losing his interest in every thing that
concerned them. Every night and morning they gathered round
his bed, and he had read some collects from the ' Visitation of the
Sick,' with the ' Grloria in excelsis.' At the end of the second
collect he always repeated aloud, with uplifted hands, the words
'Life everlasting.' All these last months was a struggle with
weakness and difficulty of breathing. He bore it all with quiet-
ness, patience, and courage. On the 20th of July he became rather
suddenly faint, and in less than half an hour passed gently away,
no one being able to tell when he ceased to breathe. He retained
his consciousness to the very last, as he had always prayed he
might be permitted to do."

If I were called upon to sum up his character in
the fewest words, I could use none more fitting than
those with which he (anonymously) has commemo-
rated his beloved brother John. He was an " example
of that peculiarly English character, the unobtrusive
but accomplished and high-minded Christian gen-
tleman."

He had outlived nearly all his contemporaries.
Two yet remain who, next to the persons of his imme-
diate family and beyond all others, were those between
whom and himself the ties of ancient friendship and
mutual affection were, I have reason to know, the
strongest. Sir John Coleridge is one of these. Both

XXX IN MEMOEIAM.

of US, indeed, are now stranded — if of liim I may
presume to say so — upon the fast-narrowing sands of
time.

Ripe in years as he was, and ready in sjoirit for
the solemn change, his death must long be the subject
of tender and sacred regret among the nearest and
dearest of his surviving family and friends; nor will
his memory soon cease to be reverently cherished
tlu'OU2"hout a much wider circle.

o

" ]Multis ille bonis flebilis occidit,
Nulli flebilior quam niihi."'

LECTURES

ox SUBJECTS CONNECTED WITH

CLINICAL MEDICINE,

COMPEISINC

DISEASES OF THE HEART.

AUTHOR'S PREFACE.

Some years ago, I published a small volume containing lectures
whicli I had given at St, Bartholomew's Hospital, with the
view of assisting the studies of those who seek the knowledge
of disease at the bedside of the patient. I believe they were
found useful ; and in that persuasion I Avould have published
other lectures with the same object. But an enlarged sphere
of duty at the hospital and elsewhere engrossed all my time,
and impaired my health, and spoiled my good intention.

The duty of physician to a great hospital, unless it can be
made easy by indifference to its highest obligations, is incom-
patible with much care of personal health. Therefore I relin-
quished my office at St. Bartholomew 's, and with it, some of the
best hopes I had of being useful in my generation.

But returning health brought back the recollection of in-
terrupted purposes, and the desire of renewing them, and led
me to think again of what I had written or remembered of
past experience, if, perhaps, I might yet glean from it a little
which would be profitable to others.

Of the lectures now published, some are literally, and some
are only in substance, those which were given at St. Bartholo-
mew's ; and others have been added to them.

Their subject is, diseases of the heart. For after all that
has been written upon it, something, I have thought, is still
wanting to bring it within the easy reach of the medical
student ; and this I have endeavoured to supply.

The treatise of Dr. Hope is very comprehensive. It em-
braces all that concerns the heart, its physiology, its pathology,
and the treatment of its diseases. But the very abundance of
its matter has made it a hard book to the student, and its style,
which is too often controversial, and even disputatious, repels
many readers, and has been in some measure a hindrance to its
usefulness. Yet it is a great work, and must always hold a

c

xxxiv authoe's preface.

higli place in the medical literature of this country. Such
information as I have to impart, has no aim of superseding
either this or any other valuable work upon the same subject,
but will rather (I trust) render the student more desirous of
consulting it, and more aj)t to consult it profitably.

Mine is a limited purpose. It is to regard the diseases of
the heart only in one point of view, i.e. as they appear in the
living man. But this one point of view includes the several
objects of their clinical diagnosis, and their clinical history,
and their medical treatment. These are what I seek especially
to illustrate, while I presume an acquaintance with other parts
of the subject, and shall only allude to them incidentally as I
go along.

The other parts of the subject, indeed, include no less than
all that belongs to the morbid anatomy of the heart, the pro-
ductions and processes which variously alter, or injure, or
destroy its organic structure. These are the very things of
which clinical observation seeks to know the living signs and
the living history and the treatment, both curative and palliative.
But these, it is no part of clinical instruction formally to
explain ; yet, unless there be some previous knowledge of them,
clinical experience cannot safely proceed : and, unless that
knowledge be kept up and improved concurrently with it,
clinical experience can never go on to perfection.

The clinical diagnosis of diseases of the heart owes all the
higher degrees of certainty to which it has been carried in our
own times, entirely to auscultatory signs. According!}- it
became necessary for me to give some account of their theory
and their uses, and I have desired to do it as simply as possible.
Their perfect theory, however, lies deeper than our present
knowledge, and all the uses of which they are capable must
wait to be developed by more and more multiplied observations
of the sick.

But already there is some true light in which these signs
may be regarded ; and already there is a large extent to which
they may be followed and trusted as the faithful exponents of
diseases of the heart. And although on this subject doubtless
there has been error and mistake, and a good deal has been
taken for more certain and something for less certain, than it
really is, so that we have both to learn and to unlearn ; yet

author's preface. XXXV

enough is already known to make the diagnosis of diseases of
the heart hardly any thing else than a just appreciation of
their auscultatory signs.

After I have described the auscultatory signs, and endea-
voured to show what they are, both in themselves and in
relation to other symptoms, and what is their value as guides
both to diagnosis and treatment, I may perhaps seem unreason-
ably to cut short the further description of the heart's diseases.

But as I lectured, so now I write, for one class of students
especially. As ray hearers were, so now I presume my readers
will be, chiefly those who are seeking information at the
bedside. To such there is no greater impediment of knowledge
than over-teaching. The teaching which they most require is
suggestive. They have the realities themselves to learn from,
the original hook to read, upon which all sound instruction is
but a commentary. Therefore the commentator should only
interpose when and where he is needed, and not after the
manner of certain critics, who most help us with their annota-
tions where the sense of the author is clear beyond dispute.

A country pastor made one of his flock a present of
Bunyan's " Pilgrim's Progress ; " and, anxious that he should
both read it and profit by it, took care that the copy which he
gave him should be one well furnished with notes. Meeting
the man some time afterwards, he asked him how he liked the
book, and whether he was sure that he understood it ; and
received for answer, that he both liked it and understood it all
well enough, except the explanations.

So with students who have free access to the wards of a
great hospital, we should not be too ready in describing and
commenting upon the ordinary phenomena of diseases which
are constantly before their eyes, lest, perchance, they should
tell us " that they understand all well enough, except the
explanations."

But there is a clinical history of diseases of the heart, as
well as a clinical diagnosis. By their clinical history, I mean
the notice of those conditions, which, whether preceding,
accompanying, or following, may be deemed to hold with them
some pathological kindred.

Every part, however, of such clinical history is not made
out with equal clearness. That which is constructed out of

xxxvi author's preface.

subsequent events, is the most full and complete. Observation
has traced back, with fearful fidelitj^, a long line of formidable
and fatal diseases to tbeir pathological parentage in the heart.
But that which is constructed of preceding or coincident
events, is hitherto less perfect ; yet observation has been able
to assign to some diseases of the heart a sure origin in, and a still
continued alliance with, diseases of other organs, or of the
constitution at large.

Now it is this last part of their clinical history which is
most available to practical purposes : how greatly available,
may be shown from the single instance of the ascertained con-
nection of endocarditis and pericarditis with acute rheumatism.
These most formidable affections of the heart have been
brought within our earlier knowledge and our earlier treatment,
and so within the greater probability of cure, by our being
fully aware when most to expect them, and then being upon
the watch for them. And all this has come from the study of
their clinical history, which has stamped their pathological
kindred with acute rheumatism.

But there are diseases of the heart which have a clear
clinical diagnosis, but no clear clinical history, except of events
which follow them ; and these are the least amenable to medical
treatment. The same signs which notify their existence,
declare their incurability. "What a gain will it be to mankind,
should observation hereafter discover that the conversion of the
valves of the heart, and the lining of arteries, into earthy
matter or cartilage, has its sure pathological origin in certain
forms of disease in other parts, or in the constitution at large,
which are both obvious and curable, or in certain habits and
modes of living which can be rectified or avoided !

The study of our times has been chiefly to specialise and to
localise disease, and it has had very useful results. But it has
had a tendency to narrow our views, and to cripple our practice
by setting up as many several pathologies within the body as
there are several organs. Yet no sooner do the diseases of
separate parts come to be treated, than they begin to claim their
place in a common pathology. We cannot reach them, and
apply our remedies directly to them, in the isolated spots
wherein we find them; but if they are to be reached, and
treated at all, it must be through the vascular system, or

author's preface. xxxvii

through the nervous system, or through the digestive and
assimilative system. For these are the common agents of life
and increase, both healthy and unhealthy, and the common
channels both of food and of medicine.

Upon the treatment of diseases of the heart, and all that
immediately concerns it, these lectures may have the appearance
of being unnecessarily prolix. But be it remembered, that
they were originally addressed to students, from whom I could
not withhold any piece of practical information which they
ought to possess, and, when I could not refer them for it to other
sources, I was obliged to furnish it myself. And still I con-
sider myself addressing chiefly students, or those who are daily
engaged in the obligations and responsibilities of their profes-
sion, and who desire to be faithful to them, and so cherish an
habitual preference for that knowledge which is useful.

All things should have a consideration bestowed upon them
in proportion to their importance : the question is, whether the
treatment of diseases has, upon the whole, had as much as is
due to it.

During the last quarter of a century, physicians have
laboured very hard, and, upon the whole, very profitably. But
their labour has been bestowed in unequal degrees, and conse-
quently with unequal success, upon the objects which concern
them. Pathology and diagnosis have had much more of their
regard than treatment. Thus our knowledge of disease in its
essence has been greatly enlarged, and our skill of detecting its
present existence and seat in the living body, has been made
more exact and sure, while our ability of influencing its
progress and events by medicine has not been proportionally
increased.

But how has this happened ? Is it that the mind, which is
best fitted for the study of pure pathology, is naturally averse
from concerning itself with practice ? One would hope not ;
but yet it may be so. The things themselves are diflerent, and
may naturally enough please diflerent minds. Disease is a
thing of itself, and admits of being studied with little reference
to other things ; and this may suit one mind. The afiair of
treating it must necessarily sufier admixture with various
accidents and circumstances of life, and cannot be conducted
•without constant reference to them ; and this may suit another

xxxviii author's PREFACE.

mind. But however this may be, the fact is certain, that to
many eminent physicians, of foreign schools especially, to
whom speculatively we owe the most, practically we owe the
least. Their lessons of pathology and diagnosis are copious,
original, and instructive ; their lessons of treatment are brief,
barren, and unprofitable.

Yet it concerns physicians, above all men, that theirs
should not be a barren knowledge, but that it should claim
honour of mankind from a sense of the benefit which they
receive from it. Far be it from me to contend, that every
piece of pathological knowledge is to be disparaged or rejected,
which cannot at once be made subservient to a practical pur-
pose. The knowledge is to be obtained at all events, and kept
ready for use, whether the use come soon, or late, or never.
Use, however, is the end always to be regarded, as well philo-
sophically as morally. An age of great increase of speculative
knowledge in medicine ought, surely, to be an age distinguished
by some great practical benefit.

It is much to be lamented that any eminent master of
pathology, who, while he is concerned with the nature of
disease, has seemed at home, and in earnest, and satisfied with
his work, pleased to instruct, and gaining favour for his
instruction as he goes along, should come at last to the treat-
ment of disease as to a humbler and less worthy portion of the
physician's care. For this ought not to be. Medicine, as it
begins to touch upon higher interests, even the interests of life
and death, should feel itself in alliance with higher motives
than any which can be thought to help and quicken its pursuit
as mere science. For now it claims a sort of moral respect in
the handling ; it calls upon the conscience as well as the intel-
lect, for more caution to avoid error, and more fearfulness of
overstepping the truth.

The treatment of diseases, rightly considered, is, in fact, a
part of their pathology. What they need, and what they can
bear, the kind and strength of the remedy, and the changes
which follow its application, are among the surest tests of their
nature and tendency.

CONTENTS.

LECTURE I.

The Natural Sounds, and Impulses and Resonances of the Heart.-^How
their variations of Degree and Extent become Evidences of the Heart's
Disease or Unsoundness - - - - - - 1

LECTURE II.

Sounds of the Heart different in kind from its natural and healthy Sounds
— to be called Murmurs. — Murmurs are either Endocardial or Exocardial
—The general Characters of each. — The Endocardial considered as the
Signs of a diseased Endocardium. — Conditions to be taken into account
in relation to them as such. — What Conditions have erroneously, and
Av hat have justly, been thought essential to their Meaning, as Signs dia-
gnostic of Valvular Disease - - - - - - 15

LECTURE III.

Endocardial Murmurs continued. — Their Origm from Valvular Disease
.sometimes doubtful. — May proceed from other Forms of mechanical Im-
pediment.— Deformed Chest. — External Pressure. — Endocardial Murmurs
sometimes confounded with the Murmur of Respiration. — A jjeculiar
^lurmur, akin to the Endocardial, a frequent concomitant of Pulmonary
Consumption. — Endocardial, arterial, and venous Murmurs, proceeding
from impoverished Blood. — Exocardial Murmurs. — Their Seat the Peri-
cardium.— Their only known Cause the Friction of its Surfaces in a State
of Disease - - - - - - - -33

xl CONTENTS.

LECTURE IV.

General Estimate of the uses of Auscultation applied to the Heart - 47
LECTURE Y.

Inflammation of the Heart. — Endocarditis and Pericarditis. — The Endocar-
dial and Exocardial Murmiu's their chief diagnostic Signs. — How tliey
become such. — The Endocardial Murmur, though found in numerous
other Diseases of the Heart, yet conditionally the sure Sign of Endocar-
ditis.— The clinical Knowledge of Endocarditis a new Knowledge. — Its
connection with Acute Eheumatism. — How it came to be distinguished,
during life, from Pericarditis - - - - - 57

LECTURE VL

Endocarditis continued. — Its general Descrijation less useful than a clinical
Commentary iipon its Individual Symptoms. — The Endocardial Mur-
mur, in Endocarditis, is sometimes preceded by a certain Roughness or
Prolongation of the Heart's natural Sounds. — Often it arises abruptly. —
Seat and Directions of the ^Murmur. — Its Accompaniments, Pain, Abnor-
mal Impulses, and Actions of the Heart. — Their Practical Value, as
Symptoms, according to their Degree, and according to the diU'erent Re-
lation which the Endocardial Murmur bears to them in different Cases. —
Their Diversities of Relation contain Intimations respecting the Stages
and Progress of the Disease. — The same confinned bj'' the Success and
Failure of Remedies. — Their practical Importance - - 64

LECTURE VIL

Pericarditis. — The Exocardial ^Murmur its pre-eminent Sign. — An imperfect
JIurmur sometimes precedes the true. — In Pericarditis, as in Pleurisy,
another Auscultatory Sign beside the Murmur, Dulness to Percussion. —
Their relation to each other not exactly the same in the two Diseases. —
In Pericarditis other Signs immediately referable to the Heart, besides
the Auscultatory : Vibrations sensible to the Touch, Undulations to the
Eye. — Other Symptoms of Pericarditis. — Their relation to its Ausculta-
tory Signs. — From these other Symptoms, and chiefly from its huown
Connection with Acute Rheumatism, Pericarditis often rightly presumed
to exist, and often successfully treated ; yet often overlooked, and often
treated too late, and often fatal, for want of the Auscultatory Signs - 74

CONTENTS. xli

LECTURE VIII.

Tlic frefiiioncy of [Eiulocanlitis uml Pericarditis, occuvrini,' separately or
together, as the Accoiiipaniiuents of Acute Rheiiinatisni. — Present llesults
of Eiiilocarditis occurring alone. — Of Pericarditis occurring alone, — Of
botli occurring togetlier. — Ditticulty of gaining Knowledge of their ulti-
mate llesults when the Cure is imperfect - - - 86

LECTUEE IX.

Inflammation of the Lungs accompanying Acute Rheumatism, either alone
or in combination with Endocarditis, or with Pericarditis, or with both.

Page 96

LECTURE X.

The Treatment of Acute Rheumatism considered, preparatory to the Treat-
ment of its Accompaniments, Endocarditis and Pericarditis.— Acute Rheu-
niatism successfully treated upon different and even opposite Indica-
tions, and by difterent and even opposite Remedies. — How this may be
A\ithout Disparagement of Medicine as a Science. — The Treatment of
almost all curable Diseases narrowed to the choice of a few Indications
and a few Remedies. — What the lowest and what the highest Office of the
Physician. — ^The highest engaged in the Treatment of Acute Rheumatism
and its Incidents. — The Groundwork of Rational Practice is to under-
stand the value of single Indications, and the power of single Remedies.
— Treatment of Acute Rheumatism upon indications belonging solely to
the Vascular System, and solely by Bleeding. — Upon Indications belong-
ing solely to the Nervous System, and solely by Opium. — Uj^on
Indications belonging solely to Abdominal Viscera, and solely by Calomel
and Purgatives - - - - - - -109

LECTURE XL

Treatment of Acute Rheumatism continued. — Its Treatment according to
mixed Indications, and by mixed Remedies. — The Blood-vessels, the
Nerves, and the Abdominal Viscera, brought simultaneously under the
remedial Impressions of Bleeding, and Opium, and Purgatives. — Advan-
tages of this Treatment. — Observations on the Use of Colchicum. —
Representations of Medical Treatment often fallacious from being too
favourable. — Commonly drawn from good Cases only ; not from all
Cases, good and bad. — The good Cases of Acute Rheumatism, or those
favourable for Medical Treatment. — The bad Cases, or those unfavourable
for Medical Treatment. — Notice of Cases in which Treatment succeeds
or fails, contrary to expectation. — Notice of Medicines, whose Ojieration
in this Disease is unquestionably Remedial, yet not understood - 127

xlii CONTENTS.

LECTURE XII.

Preventive Treatment of Rhenmatic Endocarditis and Pericarditis con-
sidered.— In the Management of Acnte Rheumatism, can any Remedy be
iised as specially preventive of, or any Remedy be avoided as specially
conducive to, Endocarditis and Pericarditis? — Is Opium preventive? —
Is Venaesection conducive? — In what their preventive Treatment really
consists. — Their actual Treatment. — It should begin with the Earliest
Notices of their Existence. — What these are in their several Varieties. —
Why, in Acute Rheumatism, the Heart, being inflamed, needs a special
Treatment, while the Joints, being inflamed, need it not. — The Treat-
ment of the Heart, however, by the same Remedies as the general Dis-
ease.— But this Treatment made special by those Remedies being used
with a different Force, and in new Directions. — Bleeding and Opium used
thus. — The Consideration of the Uses of Mercury postponed - 140

LECTURE XIII.

The general Question considered of Mercury being a Remedy for Inflam-
mation.— Condition favouring its remedial Operation. — These found in
the Nature of the Inflammation, in the Part it occupies, and in the Con-
stitution of the Patient. — Its remedial Operation either antiphlogistic
or reparatory. — The first chiefly displayed in the Inflammations of
Tropical Climates. — Parallel Forms of Inflammation hardly known in
this country. — "Wliat come nearest to them.— The Eflect of Mercury in
these not alone, but conjointly with Bleeding. — The probable Nature
of its antiphlogistic Operations infen-ed from its Effects, especially in two
Kinds of Inflammation. — Its reparatory Operation shown by Instances.

Page 157

LECTURE XIV.

Subject continued. — Antiphlogistic and reparatorj' Power of Mercury over
Acute Inflammation further illustrated by its Effects in Iritis, over
Chronic Inflammation by its Effects in Rheumatic Ophthalmia. — Its
Effects upon internal Chronic inflammation. — Our assurance of the Seat
is generally greater than it is of the Essence of internal Chronic Diseases.
— Our Conclusions, therefore, less confident respecting the Effects of
Medicine upon them. — Experience of the curative Effects of JNIercurj' in
many hidden Diseases, which from Circumstances are deemed Inflamma-
tory.— Notice of a Principle to be regarded in the Mode of Administering
it 167

CONTENTS. xliii

LECTURE XV.

Use of Mercury in the Treatment of Rheumatic Endocarditis and Pericar-
ditis.— Every great Advance of Clinical and Pathological Knowledge
requires that old Remedies should undergo the Trial of new Experi-
ments.— In Endocarditis the remedial Power of Mercury shown, not so
much by the Result of single Cases, as by the comparative Results of
many which have, and of many which have not, been treated Ijy it. — In
Pericarditis its Remedial Power may be appreciated in Individual Cases.
— The Relation which the Cessation of the Exocardial Murmur bears to
the Cessation of the Disease. — The power of Mercury to procure the
Cessation of the Murmur, early or late, according to Circumstances. —
Early Salivation most strikingly curative. — Late Salivation not without
Benefit.— Comparison of some general Results - - - 178

LECTURE XYI.

Of Endocarditis, independent of Rheumatism. — The Clinical Knowledge of
Endocarditis altogether a new Knowledge. — The Way in which it was
obtained suggests the Way in which it may possibly be enlarged. — Case
of Acute Endocarditis ingrafted upon Chronic Valvular Disease. — Cases
of Acute Endocarditis combined with Pericarditis in a previously sound
Heart. — Case of suspected Endocarditis under a more chronic Form. —
General Remarks ------- 194

LECTURE XVII.

Pericarditis independent of Rheumatism. — Shown by Morbid Anatomy to
be of common occurrence. — Its smaller Degrees the most frequent. —
Probably harmless. — Generally beyond the reach of clinical Diagnosis. —
Its greater Degrees not beyond its reach, but apt to elude it. — Why. —
Covert Acute Pericarditis and covert Acute Pleurisy compared. — Review
of Cases, with the purpose of finding what natural alliance Pericarditis
may have with other general pathological Conditions besides Rheu-
matism --.-.-. 208

LECTURE XVIIL

Immediate results of Endocarditis and Pericarditis. — Reparation of the In-
jury done to the Heart. — Perfect and imperfect. — Though imperfect, it
may save Life. — Causes which hinder or 23ostpone Reparation : 1. The
Amount of Injury to the Heart itself; 2. The Amount of concomitant
Injury to other Organs ; 3. Original AVeakness, or Pravity of Constitu-
tion.— Allusion to certain Affections of the Brain and Spinal Marrow
incident to the Period of Reparation - - - - 226

xliv CONTENTS.

LECTURE XIX.

Permanent Unsoundness of the Heart from the Injury done by Endocarditis
and Pericarditis being imperfectly repaired. — Consequences. — Secondary
Inflammations. — Their Clinical History. — Their Clinical Diagnosis. — Its
extreme Diihculty and Uncertainty. — Severe and fatal Cases. — Com-
mentary upon them at large ..... 239

LECTUEE XX.

^Secondary Inflammations continued. — Certainty of our Knowledge of
severer and fatal cases. — Eeasonable Conjecture of many less severe and
more manageable. — Inference from successful Treatment. — Does Inflam-
mation, as often as it is renewed, add something to the permanent Injury
of the Heart? — Reasons from Analogy why it sometimes does not. —
Reasons from Observation why it often does. — Case of Inflammation
many Tunes renewed in the course of Years, and ultimately Fatal. —
Commentary upon it at large ..... 256

LECTURE XXL

The unrepaired Efl'ects of Endocarditis and Pericarditis both constitute a
permanent Unsoundness of the Heart in themselves, and become the pos-
sible Elements of further Unsoundness beyond themselves. — The same
may be said of the imrepaired Eftects of other Diseases.— This further
Unsoundness a Thing difi'erent in Kind. — Natural Distinction between
the Unsoundness from Disease and the Unsoundness from Disorganisa-
tion.— Summary Account of the Unsoundness from Endocarditis ; com-
pared (by Anticipation) with the Unsoundness from other Diseases of the
Endocardium --..... 269

LECTURE XXII.

Consequences to Life and Health from the permanent Unsoundness of the
Heart remaining after Endocarditis. — 1. Cases in which beside the per-
manent Endocardial Murmur there is no other Symptom referable to the
Heart ; 2. Cases in which beside the Murmur there is occasional Palpi-
tation ; 3. Cases in which beside the Murmur there is constant Palpita-
tion .-..----. 276

LECTURE XXIII.

Permanent Unsoundness from Pericarditis ; its many Degrees : some harm-
less.— General view of the Effects of Pericarditis and of their Reparation.
— How ultimately incomplete and ending in permanent Unsoundness of
various Degrees. — Some of them specified and commented upon. —
Cumulative Unsoundness from several Attacks of Pericarditis - 285

CONTENTS. xlv

LECTURE XXIV.

Permanent Unsoundness of the Endocardium and Pericardium from
Diseases of a specific and malignant Nature, especially from analogous
Formations. — Their anatomical Character. — Their Clinical History. — ■
Their Clinical Diagnosis. — Our Knowledge of them compared and con-
trasted with our Knowledge of Inflammation - . . 298

LECTURE XXV.

Diseases of the Heart's muscular Structure. — Acute Inflammation termi-
nating in the Formation of Pus. — Cases. — Explanation of the natural
Difficulties in the way of its Diagnosis _ . . . 307

LECTURE XXVI.

Diseases of the Heart's muscular Structure continued. — Chronic Inflamma-
tion terminating in Ulceration. — In partial Dilatation. — In possiljle
Kupture. — Its Diagnosis unattained. — Cases. — The soft Heart. — The fat
Heart. — Inquiry into their Clinical Diagnosis and Clinical History. —
Rupture of the fat Heart. — Cases - - - - -315

LECTURE XXVII.

Unsoundness of the Heart from Disorganisation. — Hypertrophy. — Atrophy.
— Dilatation, — Contraction. — What they are in themselves, and in their
Combinations. — Their Clinical Diagnosis. — How far attainable by Auscul-
tation.— Their Clinical History contained in prior Diseases conducive to
them. — These Diseases may be either in the Heart or in other Parts of
the Body. — Observations upon their Clinical History, as contained in
prior Diseases of the Heart . _ . . - 334

LECTURE XXVIIL

Unsoundness of the Heart from Disorganisation sometimes traceable to an
accidental Shock which it has sustained. — This Shock a Part of the
Clinical History of its unsoundness . . . . 344

LECTURE XXIX.

Clinical History of the Heart's Unsoundness from Disorganisation con-
tinued. Causes Exterior to the Heart conducive to it. — Dilatation and

Contraction of the Aorta. — Certain Diseases of the Lungs. — Curvature of
the Spine and Deformity of the Chest. — General Disease of the Arteries.
—Coincident Diseases of distant Parts.— Liver.— Spleen.— Kidneys 353

xlvi CONTENTS.

LECTURE XXX.

Treatment of Unsoundness of the Heart in some of its i^rincipal Forms.—
Treatment of Valvular Unsoundness.— In valvular Unsoimdness tire Ex-
pectation of Medicine is not to cure it, but to stop its Increase, or to
postpone its Consequences.— The Nature of the Disease in which the
valvular unsoundness originated limits or enlarges the Expectation.—
Also the Age and Constitution of individual Patients.— Cases - 367

LECTURE XXXI.

Treatment of Hypertrophy of the Heart.— Doubts whether it he reaUy
curable.— Counterfeit Hypertrophy.— Supposed Cases of Ciu-e probably
refer to it.— True Hypertrophy.— its treatment contemplates something
short of Cure.— Blood-letting.— Limits of its Use.— Success and Failure
of Treatment.— Causes of Failure in Cases apparently favourable - 377

LECTURE XXXII.

Treatment of Atrophy of the Heart— of Softening— of Dilatation.—
Measure of expected Benefit in each . - - - 386

LECTURE XXXIII.

Effects of an unsound Heart upon the general vascular System, according to
its different Forms of Unsoundness.— Effects upon the Veins.— Effects
upon the Arteries - - - - - - - 394

LECTURE XXXIY.

General View of the secondary Diseases which proceed from an unsound
Heart, and of their Treatment. — Their vast pathological Kange. — Con-
gestions.— Effusions. — Haemorrhages. — Inflammations. — Inquiry into the
common Principle of tlieir Curability. — Curable in a higher and a lower
Sense according to the Nature of their actuating Cause. — As the result
of an unsound Heart curable only in a lower Sense. — Suspension. —
Abatement. — Temporary Eemoval possible. — Conditions limiting and
enlarging tlie Expectations of Medicine in different Cases. — Form of Un-
soundness in the Heart itself.— Presence or absence of coincident Dis-
ease in other Organs.— The natural Constitution of the Patient, whether
healthy, or plethoric, or anaemic— The Patient's Condition in Life. — The
Time at which Treatment is first instituted - - - . 408

CONTENTS. xlvli

LECTURE XXXY.

Particular View of the secondary Diseases which proceed from im unsound
Heart, not limited to any certain Part of the Body. — Tlie Lungs their
most fre({uent Seat. — The Lungs, therefore, the chief Scope of medical
Treatment. — Their nature within the Lungs. — Their mode of Treatment
and Measure of Curability greatly influenced by the Form of Unsound-
ness within the Heart. — Secondary Diseases of the Brain — of the Liver.

Page 421

LECTURE XXXVL

The Nature of Dropsy when it proceeds from an unsound Heart. — The
Purpose it serves.— Treatment. — Its Objects. — Its Success, when the
Dropsy is small, under favourable Conditions. — Its Success, when the
Dropsy is large, under favourable Conditions. — What these Conditions
are in each Case respectively . . . . . 435

LECTURE XXXVII.

Affections of the Heart, consisting in a certain Assemblage of Symptoms,
not in express Forms of Disease. — General Remarks upon them. — Their
pathological Character. — Their Treatment. — Angina Pectoris. — Its Patho-
gnomonic Symptoms. — Its efficient Cause ; not annexed to any one
Form of Unsoundness in the Heart, but probably produced by Spasm,
which is incident to many. — Sudden Death without previous Illness. —
Cases. — Probable Cause of Spasm of the Heart, or a first Attack of Angina
P^jctoris -----... 445

LECTURE XXXVIIL

Angina Pectoris continued. — Its Clinical History and Treatment. — Condi-
tions to be noted in the Intervals of its Paroxysms. — Parallel between it
and Epilepsy respecting their Treatment. — Management of the Paroxysm,
— What Auscultation teaches. — What the various Circumstances of its
Clinical History .-_.... 454

ERRATA.

Page 121, line G,for "ammonia" read " ammonite."
„ 124, „ 39, for " either ventesection" read " either in venresoction."
„ 184, „ 15, /o;- "factor" mt(^"fcctor."
„ 189, „ 7, /or "factor" mwi'Toctor."

LECTURES

ON

SUBJECTS CONNECTED WITH

CLINICAL MEDICINE

THE HEART.
LECTURE I.

THE NATUKAl, SOUNDS, AND IMPULSES AND RESONANCES OF THE
HEART. — HOW TPIEIR VARIATIONS OF DEGREE AND EXTENT
BECOME EVIDENCES OF THE HEARt's DISEASE OR UNSOUNDNESS.

Of the signs by which, we judge of the healthy and morbid
conditions of the heart, those that are called physical and are
immediately referable to the organ itself, convey the most cer-
tain information.

" A line drawn from the inferior margins of the third ribs
across the sternum passes over the pulmonic valves a little to the
left of the mesial line, and those of the aorta are behind them,
but about half an inch lower down. A vertical line, coinciding
with the left margin of the sternum, has about one third of the
heart, consisting of the upper portion of the right ventricle, on
the right, and two thirds, composed of the lower portion of the
right ventricle and the whole of the left, on the left. The apex
beats between the cartilages of the fif thandsixth left ribs at a point
about two inches below the nipple, and an inch on its sternal
side."*

This is the pra)Cordial region, in which the basis and apex
and lateral boundaries of the heart are denoted, and its entire
outline is traced in relation to the walls of the chest.
* Hope on Diseases of the Heart, p. 3.

1

2 CLINICAL MEDICINE. [lECT. I.

Within this space we cannot see. But at this space we can
listen, and feel, and knock, and so put it to question, whether
all be riorht beneath. And there is no spot of it which does not
in its turn make answer to the ear, to the touch, or to the
tapping of the finger, and tell something of the organ that lies
herein. Hence proceed sounds, some of health and some of
disease, which of the two the ear must judge. Hence are conveyed
impulses, some of health and some of disease, which of the two
the toiicli must tell.

All this may seem strange at first. But it will seem no
longer strange, when we consider that inseparable from the
functions of the heart is a certain motion or energy, and that it
varies according to its conditions of health and of disease ; and
that inseparable from this motion or energy are certain sounds
and impulses, and that these vary as it varies. Hence these
sounds and impulses have natural degrees and qualities, a natu-
ral order of succession and a natural limit of extent, which the
ear and the touch can appreciate and use as a measure of the
heart's health. And hence these sounds and impulses admit of
deviations from their natural degrees and qualities, and their
natural order and extent, which the ear and the touch can, in
like manner, appreciate and use as a measure of the heart's
disease.

Now it is evident that our enquiry must begin with the
natural and healthy sounds and impulses of the heart. These
are the standard of comparison, by which alone we can judge of
the unnatural and morbid.

First, then, of its sounds. And here, for the sake of avoiding
confusion, let me just mark the distinction between the sounds
which reach the ear simply by listening, and those which reach
it by help of percussion. Though the ear judges of both, yet
are they totally different in the modes of their production. The
heart itself produces the former by its own vital movements. We
produce the latter, and the ear is made perceptive of them only by
our knocking. The heart contributes nothing but as an inert
mass; and what it contributes as such is found equally in the
dead and in the living. It is the sounds which the heart brings
out of itself by its own vital movements, that I wish now to
consider. The sounds, which we bring out of the heart by our
percussion, I will consider hereafter : for they too carry with

LECT. T.] THE SOUNDS OF THE IIEAUI'. 3

thoui notices of health anil ol" disease, which are iKMthcr few nor
aminiportant.

The sounds, -which naturally accompany the movements of
the healthy heart, can only be learnt by the practice of listen-
ing to them. It is useless to describe them. They are simple
perceptions of sense, which no words can make plainer than they
are, when the ear has once become familiar with them. It is
the same with all common sounds. Jiy describing them you
seek to make them known in a different way from that in which
they are naturally known. Who ever thought of describing the
sound of the wind or the rain except for pootical purposes ? I
must leave you, then, to be your own self-instructors in the
healthy sounds of the heart, and recommend you to be con-
stantly practising auscultation for the purpose on healthy
subjects.

But, besides the fact, that sounds of a certain kind accompany
the healthy actions of the heart, which each man must listen
for and so learn for himself, there is the theory of the fact, or
the explanation how these sounds arise. This surely cannot be
learnt merely by listening. The fact that it rains or it blows, we
may take upon ourselves to decide without the philosophers,
because wo hear it. But, if we would know how it comes to do
either one or the other, if we would understand the theory of
winds and showers, we must enquire a little further, and betake
ourselves for instruction to those who have examined into such
matters.

In listening at the pr;r(Cordial region, the ear at once per-
ceives two sounds proceeding from the heart, — the one duller
and more prolonged, the other clearer and shorter ; the one
coinciding with the systole of the ventricles and the pulsation of
the arteries, the other coinciding with the diastole of the
ventricles and the rest of the arteries. Hence it appears that for
one pulsation of the arteries there are two sounds of the heart.

But between the two sounds of the heart there is hardly an
ai^preciable interval. The duller sound, which goes for the
first, seems to end with a snap, which goes for the second ; and
then succeeds an interval of repose, which is appreciable enough
before the duller sound returns.

The time, thus occupied by the sounds of the heart in their
succession and their pause, has been divided and accounted for

4 CLINICAL MEDICINE. [lECT. I.

after this manner :— one-half is filled up by the first sound, one
quarter by the second, and one quarter by the pause.

Still, though there be hardly an appreciable interval between
them, the ear acknowledges two sounds. And, that they are
really two, will appear the more certain, when their efficient
causes are found to be different. So much as is either known
or plausibly conjectured about these causes I will now briefly
state.

About the efficient cause of the first normal and natural sound
of the heart there is, I am afraid, a good deal still in debate.
After many direct experiments still physiologists do not agree.
Pathologists and physicians then may well be pardoned any
doubts and difficulties they may have about sounds which are
abnormal and unnatural.

It is very plausibly conjectured that the efficient cause of the
first sound is pretty equally shared between the muscular struc-
ture of the ventricles and the auriculo-ventricular valves, and
that both, by the conditions under which they are placed during
the systole, directly contribute to it : the muscular structure,
by its contraction, giving it length and dulness, and the valves,
giving it a perceptible sharpness by their extension.

But what of this perceptible sharpness ? Here is a new appeal
to the ear. Does the ear acknowledge it ? Is it indeed a
perceptible ingredient of the first sound under ordinary circum-
stances ? For my own part I cannot tell.

It is admitted, however, that, in the healthy heart, this sharp-
ness of the first sound is muffled by its predominant dulness.
But it is said that there it is notwithstanding, and that there are
states of the heart which demonstrate both its reality and how it is-
produced : that, in proportion as the muscular structure becomes-
attenuated, the first sound loses more and more of its dulness-
and length, and gains more and more of this sharjmess, which is
then not merely manifest but predominant, and sometimes exists-
alone ; and again, that in proportion as the muscular structure-
becomes thickened, the first sound gains in dulness and length,
and then that its sharpness is not only muffled, but absolutely
absorbed and abolished.

If all this be true, the first sound of the heart is a mixed
sound, or rather two sounds so blended together in the healthy
organ as to be nearly or altogether indistinguishable, and so to

LECT. I.] THE SOUNDS OF THE HEART. 5

pass for one. Disease, however, is able to analyse them for ns,
and, presenting tlicm separate to the car, makes now one and
now the other predominant.

But there is yet another condition which claims a part in
causing the first sound of the heart.

The muscular contraction of the ventricles already spoken of,
as having its share in the efficient cause, is the same which the
heart exercises in common with other muscles of the body. But
there is said to be, besides, a muscular tensio)/, which is
peculiar to the heart. This peculiar tension takes place
"when the blood is poured in from the auricles, and the
valves are closed, and the ventricles are filled, and their muscu-
lar fibres braced up, and their entire muscular mass becomes for
a moment as hard as cartilage. At this moment it is that the
tension reaches its acme and gives a sound. And this sound of
muscular tension mingles with the sound of the auricular valves,
which are then upon the stretch, and the sounds of both
mingle witli the sound of muscular contract ion which, immediately
follows.

If this be true, the first sound of the heart is a compound of
three sounds, each having its own separate efficient cause.

This is rather an intricate piece of physiology. Yet it con-
tains (I am persuaded) some truth. But then it looks so like a
riddle, and needs so much trouble to understand and explain,
that one cannot take it and use it as a ready clue to explore
diseases with.

In the first sound of the heart, which is apparently one, there
may be two or three efficient causes involved, operating simul-
tnneoushj, and producing, in fact, two or three sinmltaneous
sounds. Bearing this theory in mind I may find, perhaps, that
it now and then helps me a little to explain certain auscultatory
phenomena, which attend diseases of the heart. But for daily
use I am content to let my ear dictate to my understanding, and
to believe, that the first sound of the heart is one sound, and
that one cause is engaged in jii'oducing it, viz. the muscular
contraction of the ventricles.

Here, at the threshold of our subject, I would make one
general remark, which will find its application as we go along,
viz. ihat it is not all physiology which can be made useful
towards the knowledge and treatment of diseases, but only those

6 CLINICAL MEDICINE. [lECT. I.

parts of physiology whicli are undeniably true, and not only
true, but easily and at once seen to be so. A great deal of what
is termed phj'siology has turned out to be a mistake ; and so far
us it has got mixed up with our notions of disease (and this has
happened to a deplorable extent), it has hindered the progress-
of practical medicine.

The efficient cause of the second sound of the heart admits of
little doubt. Though it take place during the diastole of the
heart, yet is it in no way produced by the alterations of form
and consistence which the ventricles then undergo. Their re-
lapse from a state of tension to a state of flaccidity has nothing
to do with it ; hut the second sound of the heart results simply
iVom the sudden closure of the sigmoid valves by the recoil of
the blood, when it is thrown back upon them from the pidmonary
artery and the aorta.

So much concerning the normal and natural sounds of the
heart. As to the sounds themselves, since the ear can only
become familiar with them by practice, I leave you to be your own
instructors. As to their theory, taking the matters of fact and
matters of speculation which have been brought to bear upon it,
I consider that it is in part satisfactorily made out, and in jDart.
only plausibly surmised. In the received theory of the second
sound I am content to acquiesce ; but I look to future experi-
ments for something clearer and simpler before we can finally
rest satisfied of our possessing a true theory of the first.

Of the natural and healthy limit of the heart's sounds within
the chest something must next be said. It is a jDrcliminary
point which some have thought most important to be determined
with precision. But no good ever comes from pretending to.
more precision than the thing itself admits of ; and I am sur(^
this matter does not admit of much. The pnxicordial region, it
has been said, defines it. But surely the second sound always
exceeds that limit, and is audible also in the course of the aorta,
and of the pulmonary artery and of the carotids. Indeed,
nothing less could have been expected ; this sound having its-
efficient cause in the mechanical closure of the valves whicli are
placed at the entrance of the aorta and the pulmonary artery
respectively.

With respect to the first sound, I should be at a loss to mark
the exact space within which healthy proportion and healthy

LECT. I.] THE SOUNDS OF THE HEART. 7

structure always required it to be lu^ard, and in neither more
nor less. There arc so many circumstances, some consistent
with health in the largest sense, and some exclusive at least oi"
its disease, which make the systolic sound of the heart more or
less extensively audible, that (I am persuaded) two healthy
persons would not easily be found in whom it would be heard
exactly within the same thoracic space. Whether a man be fat
or lean will always make a great difference. In the one it will
be kept within the pra;cordial region, in the other it will be
carried beyond it. Fat is so bad a conductor, that where it
greatly abounds, it will restrict the sound to less than the entire
priccordial region, even to a very small part of it ; so that you
will not bo able to hear the heart further than you can feel its
impulse, or further than its apex. But mere skin and bone are
such good condvictors, that in very thin persons the sound will
spread very far beyond the pr?ccordial region, and be heard at
any part of the chest to which you apply your ear.

I believe that in most persons of (what is called) a nervous
temperament, even when they are under no conscious excite-
ment, the heart's sounds are to be heard beyond the praecordial
region, and, under actual emotion, very far beyond it. And I
believe too that in persons of this temperament the heart's
sounds are apt to be of a higher intonation. One condition, no
doubt, is the result of the other. In proportion as the sounds
of the healthy heart are more highly intonated, they acquire a
greater audible extent. The louder they are, the further you
hear them. And it is the very characteristic of a nervous
heart to have its sounds both highly intonated and extensively
audible.

The greater extent and louder intonation of the heart's
sounds may be no direct symptoms of disease or unsoundness
in the organ itself : but they may be, and often are, indirect
symptoms of disease or unsoundness appertaining to other parts
within the chest. Whatever gives more than their natural
solidity to the contents of the chest ; pulmonary deposits, in-
flammatory or tubercular ; thickened walls of vomicce, a thick-
ened pleura and fluid within its cavitj'', aneurismal tumours,
and foreign growths and curvatures of the sj)ine ; all these,
partly from the compression which they exercise upon the
lungs from within or from without, and partlj'- from the amount

8 CLINICAL MEDICINE. [lECT. I.

of solid matter appertaining to themselves, give to the sounds
of the heart a larger audible sphere within the chest, and exalt
their natural intonation.

It is well to be aware of all this. Not that the heart's
sounds, by their greater audibility and extent, can do more
than intimate the possible existence of some such forms of
disease. The diseases themselves are discoverable by their own
direct signs, and there is no need of questioning the heart con-
cerning them. Only we should take especial care that what
from extrinsic circumstances seems wrong about the sounds of
the heart, be not wrongfidly brought in evidence against the
heart itseK,

But, besides the sounds naturally annexed to the motions
of the heart in its state of health, there is its impulse.

Now the fact of the heart's healthy impulse must be left
entirely to the touch without further description, as that of its
healthy sounds was to the ear. But there is a theory of its
impulse lying beyond the immediate reach of the senses, which
serves physiologists to dispute and doubt and reason abovit, but
not to agree. How many efficient causes, or rather how many
various instruments making up the efficient cause, have been
spoken of as engaged in producing that single stroke which we
feel between the fifth and sixth rib, I will not pretend to say.
I confess that no theory of any complex agencies beyond the
heart is verified to my apprehension. As the impulse is syn-
chronous with the contraction of the ventricles, and the con-
traction of the ventricles is surely adequate to produce it, Avhy
should we not believe that it does so altogether ?

The normal limit of the heart's impulse is somewhat more
certain than that of its sounds ; the space within which, neither
more nor less, healthy structure and healthy proportion require
the heart to be felt is more certain than that within which tliey
require it to be heard. But still there are circumstances, and
those not inconsistent with health, which interfere with the
sensible impulse of the heart, now restricting and now extend-
ing it. The same man, according to the varying postures of
his body, will alter the place and extent of this impulse. He
stands up, and makes it felt just where the apex strikes the
chest, at a point between the fifth and sixth ribs, and not
beyond it. He leans forward, and makes it felt both at this

LKCT. I.] THE SOUNDS OF THE HEART. 9

])oint und a little above it, and in the direction of the sternum.
lie reclines upon liis back, and renders it almost or altogether
imperceptible anywhere, lie turns on his left side, and renders
it more perceptible than ever, and in a somewhat larger and
different space, between the fifth and sixth ribs, and from
thence more towards the mamma than the sternum. Again, he
turns on his right side, and again he renders the imj)nlse almost
or altogether imperceptible.

How all this comes to pass is so obvious, that it needs no
explanation. The facts themselves, however, are worth bearing
in mind.

Moreover, many of the same conditions, some entirely con-
sistent with health and some exclusive of disease in the heart
at least, which make its sounds more or less extensively audible,
are found capable of making its impulse more or less exten-
sively felt : sucli as redundancy and want of flesh, and the
proximity of consolidated structures, by a plain and appreciable
operation ; and such as the nervous temperament, by a more
mysterious, but not less certain, influence.

But, besides the sounds and impulse of the heart, which
come from its own vital movements, and cease, when it ceases
to live and to move, there are other sounds belonging to it, —
sounds with which its vital movements have nothing to do, and
which are (as already stated) entirely produced by our percus-
sion of the pra^cordial region. These should rather be called
resonances than sounds. They tell of solidity and hollowness.
And they tell the same equally, whether the man be alive or
dead ; though our concern with them, as physicians, is only
when he is alive.

Take the fifth costal cartilage on the left side, and let a
point, midway between its junction with the sternum and its
junction with the rib, be the centre of a circle two inches in
diameter. This circle will as nearly as possible define the space
of the pra)Cordial region, which is naturally less resonant to
percussion than the rest. In reckoning thus we suppose the
frame- work of the chest fairly proportioned, no chicken-breasted
sternum, no curvature of the spine, lateral or anterior, and all
the organs within sound, and bearing their due relation of
position to each other. Here the heart is uncovered except by
the pericardium and a loose cellular texture, and may be said

10 CLINICAL MEDICINE. [lECT. I.

to lie in contact with the walls of the chest ; while in the rest
of the pnccordial region it is covei'ed, and separated from the
walls of the chest, by the intervening- lung.

In the space indicated, most practical men would (I think)
be ready to admit that percussion conveys to the ear a sense
rather of less resonance than of positive dulness. The fact is,
if the percussion used be but of moderate force you must listen
attentively to make sure that the resonance is really less here
than elsewhere. It is only when the percussion used is of a
force somewhat painful to the patient, that the ear begins to
acknowledge a jjositive dulness.

It is well to be aware, that the erect posture is more favour-
able than the recumbent for makina: this dulness or diminished
i-esonance perceptible to the ear ; and the instant of exsjairation
than the instant of inspiration. In the recumbent posture the
intervening loose cellular texture is not strong enough still to
keep the heart close to the sternum and the ribs, and prevent
its receding by the force of gravity. And during inspiration
either a larger i^ortion of lung may be brought in front of
the heart ; or the portion which is always in front of it may be
so thickened by inflation as to thrust backward, for the time,
more of the heart than it actually covers.

Such are the sounds, the impulses, and the resonances, which
belong to the healthy heart. Remember, the sounds and im-
pulses are inseparable from it as a living organ, and are brought
out by its own vital movements. And remember, the reso-
nances are only conditionally annexed to it as a passive sub-
stance, and are brought out by our percussion.

The short physiological account of them, which has just
been given, will probably be found useful to us as we proceed.
At all events we may make a platform of it, where we think it
will bear us, and tread more cautiously upon it, where we think
it will not.

Of the sounds, impulses, and resonances of the heart no
other varieties have thus far been mentioned than those of
degree and extent. And indeed its impulses and its resonances
admit of no other varieties, either in health or in disease. But
the sounds of the heart admit, moreover, of varieties in kind,
which will afford abundant matter for consideration hereafter.

IJut let us clear up the subject as we go along, and first

LECT. I.] THE SOUNDS OF THE IIKAKT. 11

uiulcrstaiid how- from the sounds, the iinpulsos, and the reso-
nances of the unsound or diseased hearl, these being jiist the
same in kind as of the healtliy lieart, only more or less in
dej^rec or more or less in extent, we are able to gather such
important intiniations concerning the nature of its unsoundness
or its disease.

A clearer sound proceeds from a thin heart and a duller
sound from a thick lieart ; a sound of greater extent from a
large heart, and a sound of less extent from a small heart. A
more forcible impulse is given by a thick heart, and a feebler
impulse by a thin one ; the impulse is conveyed to a longci-
distance from a large heart, and to a shorter distance from a
small heart.

All this is surely plain enough, and it is undeniably true.
Nevertheless, from its sounds taken alone and from its impulse
taken alone, we could come to few trustworthy conclusions re-
specting the structural condition of the heart. And why'r
liecause its sounds and its impidses are capable of being aug-
mented or lessened, both in degree and in extent, by causes
extrinsic to the heart. This has been expressly stated already;
and these extrinsic causes have oftentimes a power over its
sounds and impulses as great as any which the heart itself
derives from diseases of its own. This will be abundantly
shown hereafter.

But, happily, sounds and impulses are the interpreters of
each other. The true meaning of the sound is tested by the
impulse, and the true meaning of the impulse is tested by the
sound.

Thus, from a clearer sound, we argue only the probability
of an attenuated heart ; but we argue its certainty from a
clearer sound joined with a weaker impulse. From a stronger
imjjulse we argue only the probability of an hypertrophied
heart ; but we argue its certainty from a stronger impulse
joined with a diminished sound.

When impulse and sound increase together, there is pro-
bably no hypertrophy, but the heart is only acting more
forcibly from pure excess of nervous energy. When impulse
and sound decrease together, there is probably no atrophy, but
the heart is only acting more feebly from pure defect of
nervous energy.

12 CLINICAL MEDICINE. [lECT. I.

When the sounds and impulse of the heart are both per-
ceived beyond the proccordial region, they give notice (generally
sjDeaking) of dilatation of one or other of the ventricles. If,
under these circumstances, sound predominate over impulse,
then with dilatation there is cither attenuation, or somewhat
less than a proportionate increase of its muscular substance.
If impulse predominate over sound, with dilatation there is
either hyjaertrophy or somewhat more than a proportionate
increase of its muscular substance.

Thus it is seen how much information respecting many, the
most important structural changes, which the heart is liable to
undergo, may be conveyed merely by the greater or less inten-
sity, and by the greater or less extent, of its sounds and
impulses.

But, amid these sounds and impulses, what is the place and
what the value of percussion? Wait a moment, and we shall
see. For this matter of percussion must first be cleared a little
of certain difficulties, which, lie in the way of our rightly
understanding its diagnostic uses in application to the heart,
before Ave can well see what those uses are.

Call to mind the important distinctions between the sounds
proceeding from the heart, which reach the ear from simple
auscultation or mere listening, and those of which the ear is
made perceptive by percussion. The same distinctions hold
good between the sounds of auscultation and percussion, from
whatever organ they proceed.

Xow there is an auscultation and a percussion of the lungs
as well as of the heart.

Auscultation exercises over the lungs and over the heart a
peculiar and separate domain, ascribing to one and to the other
what is properly its own, and marking it with a distinctive
character, both in health and in disease. But percussion holds
a mixed domain over both, leaving undistinguishable hj any
certain mark what naturally belongs to either, both in health
and in disease.

The sounds of the heart, caught by mere listening, and
made by its own vital movements, are std generis. They cannot
be mistaken for anything else but what they are: they cannot
possibly be mistaken for the sound of the lungs. And so too
the sounds of the lungs, heard by mere listening, and coming

LECT. I.] THE SOUNDS OF THE HEA.UT. 13

from their own vital movonients, aro siii gencrk. They too
cannot be mistaken for anything but what they aro: they
cannot possibly be mistaken for the sounds of the heart.

But the sounds of whicli the ear is made perceptive by per-
cussion, whether they be elicited from the heart or from the
lungs, are mere degrees of resonance or non-resonance: they
have nothing in them which is >iul generis. Those whicli respect
the heart may bo mistaken for those which respect the lungs,
and vice versa. Nay! the sounds elicited by percussion from
foreign substances which have their accidental growth and seat
within the chest are not at all different from those belonging to
the lungs and the heart.

Percussion may find the whole proecordial region dull, and
much more than the precordial region. The dull sjDace may
extend beyond it laterally, and reach from mamma to mamma ;
or it may extend upwards, and reach as high as the second or
even the first rib on the left side, and thence, spreading beneath
the sternum, reach nearly as high on the right. And all this
may be caused by the heart enormously enlarged in all its
dimensions. The heart, as it goes on enlarging, pushes the lungs
aside, and comes itself almost in complete contact Avith the
walls of the chest anteriorly. Still it may not be caused by
the heart, but by solidified lung, or by pleural effusion, or by
an aneurismal tumour, or by some vast morbid growth. By
which of them, however, percussion alone cannot decide.

Thus, from the sameness of its immediate results, wlien it
is applied to test the diseases of organs within the chest, per-
cussion alone can teach us little. And so percussion, if we
begin with it, is an useless manoeuvre. But percussion as an
auxiliary, and in its proper place and turn, is worth a great
deal. It is so especially with reference to the heart and its
diseases.

We must first listen at the proocordial region with our ears,
and examine it with our hands. And thus we may learn all
that is capable of being known concerning the condition of the
heart: the heart may disclose the whole secret of its disease b^-
its sounds and impulses. Or thus we may onl}^ learn a small
part of what is capable of being known: the heart may only
give an intimation of its disease by its sounds and impulses,
and we may still want the means of further information. Here

14 CLINICAL MEDICINE. fLECT. J.

percussion is often able to supply all the lielp that we have necfl
of: it often comes in as an opportune expositor of the disease,
and often stamps a certainty upon our diagnosis, which would
be utterly unattainable without it.

Whatever forms of disease or unsoundness have the eflPect of
augmenting- the general bulk and compass of the heart, lie
especially within the reach of percussion, and within the possi-
bility of deriving illustration from it. Diseases which issue in
superadded substances, in serum or lymph, or pus or blood,
accumulated within the pericardium ; forms of unsoundness
which consist of thickened muscular structure, or more capa-
cious cavities, or of dilatation with hypertrophy, or dilatation
with attenuation, all admit of being better understood by help
•of percussion.

LECT. II.] ON HEART MUILAIUUS. 15

LECTURE II.

SOUNDS OF ■riiE m:Airi' dii'fekent ix kind from its natural

AND HEALTHY SOUNDS — TO BE CALLED MURMURS. MURMURS

ARE EITHER ENDOCARDL\L OR EXOCARDIAL. THE GENERAL

CHARACTERS OF EACH. THE ENDOCARDIAL CONSIDERED AS

THE SIGNS OF A DISEASED ENDOCARDIUM. CONDITIONS TO BE

TAKEN INTO ACCOUNT IN RELATION TO TIIEM AS SUCH.

WHAT CONDITIONS HAVE ERRONEOUSLY, AND WHAT HAVE
JUSTLY, BEEN THOUGHT ESSENTIAL TO THEIR MEANING, AS
SIGNS DIAGNOSTIC OF VALVULAR DISEASE,

Of impulses of the heart we know no other varieties than
those of degree and extent: and of sounds brought out of the
heart by our percussion (tliat is of resonances), we know no
other varieties than those of degree and extent. But of sounds,
brought out of the heart by its own vital movements, Ave know
many other varieties, which are both different in kind from any
that are heard in health, and different too from each other.
These arise from divers (conditions of disease, and so become
the evidences of their existence.

This part of the subject, which respects sounds oi the
heart, different in kind from the natural and healthy sounds,
has been rendered unnecessarily difficult by over-refinement.
But surely this ought not to be. Any method by which we
seek to make things, in their own nature confessedly perplexed
and difficult, better understood, should itself be made as little
perplexed and difficult as possible. If Auscultation is to bo
trusted for perfecting our diagnosis of diseases of the heart,
auscultation must be simple.

These sounds of the heart, different in kind from the natural
and healthy, have obtained many curious names from similitudes
they bear to sounds of more familiar occurrence. Thus they
have been called the sounds of the bellows, the saw, the i-asj).

IG CLINICAL MEDICINE. [lECT. II.

the file ; and the whistling and the cooing sound, and the sound
of crumpled parchment, and the churning, and the rubbing,
and the to and fro sound.

ISow all this music or discord (call it which you will) has
some reason in it, as we shall find hereafter. But we must
leave it for the present, and begin with something less likely to
confuse us.

rirst, then, for the sake of avoiding the constant recurrence
of the same epithets, let us agree to designate all sounds of the
heart, which are unnatural in kind, by the name of Murmurs.
And, inasmuch as they are always produced b}' conditions found
either within the cavities, or upon the external surface, of the
heart, either inside or outside of it, let these murmurs be called
Endocardial or Exocardial.

The endocardial murmur is not only different in kind from
the natural sounds of the heart, but it takes their place, and is
heard in their stead. It comes exactly where the first sound,
or where the second, or where both sounds should be. It keeps
strict time with the systole or with the diastole of the heart, or
with both.

The exocardial murmur, too, is difierent in kind from the
natural sounds of the heart. But it does not take the place of
them. It is not heard in their stead. In proportion as it is
louder, it obscures or overj)owers the natural sounds. But the
natural sounds are still apt to reach the ear through the exo-
cardial murmur; and, when they do not reach the ear, it is
because they are imperceptible under the circumstances, not
because they cease to exist.

It would be time and trouble thrown away to dwell long
upon these endocardial and exocardial murmurs, with a view
of describing Avhat they are in themselves and in contrast with
each other. For after all every man must learn them for him-
self by the teaching of his own ear. Touching, however, our
mere perception of them as sounds, there are a few circum-
stances interesting enough to mention, which may chance to
help the ear to a readier acquaintance with them.

"Whenever we hear any unusual sound, cither for the sake
of conveying our notion of what it is to another, or often I'or
the sake of being sure that wo have a right notion of it ourselves,
we are apt to set about imitating it. Now, any man hearing

LEC'T. .II.] OX illLVUT MURMURS. 17

tho endocardial murmur for the first time, as it occurs in tlio
great majority of cases, would be almost sure to try and imitale
it witli his mouth, and what with whistling and blowing, ho
would presently hit upon something so very like it, as to make
him pleased with his own cleverness. But, hearing the exo-
cardial murmur, such as it is in the majority of cases, for the
first time, he would never think of imitating it with his mouth;
he would rub his hands together or the cuffs of his coat, or take
up any two things within his reach — two pieces of thick paper,
perhaps — and rub them together, and, what with brushing,
and rustling, and crumpling, he would presently bring out a
ver}^ near counterfeit of the exocardial murmur.

But these murmurs are to be caught quickly, and dis-
tinguished surely, and turned to a ready use, only by practice.
Yet it gives a previous confidence in the reality of a distinction
between them, to know that the endocardial murmur conveys
to all ears the idea of hloicing, and the exocardial murmur the
idea of two bodies moving in contact with each other.

It may be further stated among their general characteristics,
that the endocardial murmur is most frequently a single sound,
being coincident either with the systole or diastole of the heart ;
yet that sometimes it is a double sound, being coincident with
both ; but that the exocardial murmur is rarely less than a
double sound. Moreover, that the endocardial murmur is
commonly more inward and deeper, and further from the ear,
and the exocardial murmur more outward, and nearer to the
surface, and closer to the ear.

And now for the modes in which these murmurs arc
severally produced, or their efiicient causes.

First, then, as to the endocardial murmur : it results
principally, and most frequently, from unusual vibrations com-
municated to the particles of the blood by obstacles, which it
encounters in its passage through the heart. The obstacles
which thus set the whole conflict a-going are inherent in
certain portions of the endocardial membrane rendered unsound
by disease. It is possible, indeed, for the blood, sjDontaneously,
or at least independent of any known obstacle which it en-
counters, to allow vibrations among its particles from which the
true endocardial murmur may arise. Cases showing the fact
are not of unfrequent occurrence. They form a class of them-

2

IS CLINICAL MEDICINE. [lECT. II.

selves; and. a very interesting class it is, and deserving our
separate consideration. At present, however, we will limit our
attention to the endocardial murmur, which has its origin in an
unsound portion of the endocardial membrane.

The membrane which lines the cavities of the heart is very
liable to disease, but not equally so in every part. Where it is
thin and transparent, and admits the colour and character of
the muscular structure upon which it is spread to be seen
through it, it is seldom found diseased ; but where it is of a
denser structure, either in itself or from an admixture of other
structures, whether cellular or fibrous, with its own, it is
frequently and often exclusively diseased. This character of a
denser texture belongs to it where it forms the tough white
circles which surround the apertures of communication between
the auricles and ventricles : also where it is reflected upon itself,
and forms the loose duplicatures of membrane which are given
off, as it were, from the internal surface of the heart, either at
the fibrous circles intermediate between the auricles and ven-
tricles constituting the tricuspid and the mitral valves, or at
the commencement of the pulmonary artery and the aorta,
constituting the semilunar valves.

It is remarkable how curiously disease is apt to limit itself
to the spaces just pointed out. Of the fibrous circle between
the auricle and ventricle, of the valves which originate from it,
and of the tendinous cords which connect the valves with the
carneae coluranoc, there will not perhaps be the smallest space
free from disease ; but the disease will abruptly stop where the
tendinous cords cease and the carnese columna) begin. The
membrane, however, where it covers the fleshy columns of the
heart, is not exempt from the possibility of disease ; but, when
disease actually affects it, it has seldom originated there, but has
generally spread from other parts of the same membrane,
although (as we have just remarked) it is apt to stop short
before it reaches it.

Observe, I here speak of disease in the loose sense in which
it is commonly taken, the sense, in which a very small part is
made to stand for the whole. I mean only its local products
and results, not its vital actions and processes, which mainly
constitute its essence.

Any material product, then, of disease of the endocardium,

LECT. II.] ON HEART MURMURS. 19

a pearl of lymph adhering to it, a loose excrescence hanging
from it, any interstitial thickening, any deposit of earthy matter
or cartilage, is enougli to produce an eddy of the blood, and so
ffive occasion to the endocardial murmur. Hence wherever this
murmur exists we are at once led to think of an unsound endo-
cardium ; but we cannot at once be sure that it is actually
unsound. For the exceptional cases, in which the murmur is
coincident with a sound endocardium, are by no means rare.
As soon, however, as upon reflection we have reason to believe
the endocardium actually unsound, we may be almost sure that
it is unsound in some portion constituting a valve. For the
exceptional cases are indeed extraordinarily rare, in which
unsoundness is found affecting other parts of the endocardium
and leaving the valves intact.

Of all parts of auscultation there is none more interesting
than the diagnosis of valvular disease by means of endocardial
murmurs. The history of its progress to its present degree of
completeness is itself most interesting and instructive. I will
give a short sketch of it.

And, first, I woidd remark generally, that, with respect to
the physical signs esj)ecially which denote disease of the endo-
cardium and its valvular structure, as well as disease of the
pericardium, the student, who starts from the level of our
present knowledge, has a vast advantage over those who are his
predecessors by a few years. He can be at once put in the way
•of so surely convincing himself of certain truths, that, by a
little careful observation, he will soon make them parts of his
own knowledge and experience ; whereas we were obliged to
work them out for ourselves.

Laennec has indeed been in our hands for nearly these thirty
years. And Laennec was the great originator of the auscultatory
method of diagnosis in its application to the heart more strictly
and especially than in its application to the lungs ; and without
him to show us the way, this rich and ample field of enquiry
might never have been known or cultivated at all. But
Laennec, in working out his proofs in detail, admitted some
capital errors, which had well nigh made shipwreck of the whole
discovery for any useful or practical purpose. Such was that
error of his which ascribed (what is called) the second sound of
the heart to the contraction of the auricles.

20 CLINICAL MEDICINE. [lECT. II.

Now the miscliief did not so mucli consist in making tlie
auricles contract with a sound, as in taking the sound thus
produced for a notice of time, to which he referred certain un-
natural murmurs, and fixed their seat and determined their
import accordingly. As thus ; all murmurs coincident with, or
immediately consecutive to this contraction of the auricles, i.e.
taking place of the second sound of the heart, he held to denote
disease of the valves which immediately succeed the auricles in
the course of the circulation, viz. the tricuspid or the mitral.

You may conceive what errors of diagnosis must have
followed the general acceptance of this erroneous matter of fact.

The proof, by experiment, that the auricles have nothing to
do with the second sound of the heart, or with any sound at all,
was the first great step towards a safer and surer appreciation of
the diagnostic value which belonged to endocardial murmurs.

Still we did not get on. It was easy to affirm, from the
j^resence of endocardial murmurs, that valvular disease existed.
And the more prudent and more experienced learnt to be content
with affirming thus much and no more ; while the less wary,
who ventured to commit themselves to a diagnosis of the par-
ticular valve which the disease occupied were very often wrong.

Still (I say) we did not get on. Still we were striving in
vain to reach a more accurate knowledge of valvular disease by
means of endocardial murmurs. And the main obstacle to our
success turns out to have been another error of Laennec, con-
sisting in a certain fallacious canon which he laid down, and
which was for a long time generally accepted upon the warrant
of his authority.

The fallacious canon was this, that each cavity of the heart
was instrumental, by its contraction, in producing the murmur
which proceeded from the injured valve immediately beyond
itself. Thus, when the aortic valve was injured, the systole of
the left ventricle produced the murmur by forcing the blood
through the narrow aortic orifice. "When the mitral valve was
diseased the systole of the left auricle produced the murmur by
forcing the blood through the narrow auriculo-ventricular orifice.
And since the first natural sound of the heart came from con-
traction of the ventricle, and the second sound (as was thought)
came from the contraction of the auricle, it was only necessary
to ascertain in the place of which of the two sounds the murmur

LECT. Il] on heart MURMURS. 21

came, that you might be sure which of the two valves was
diseased. If in the place of the first, it was the aortic ; if in the
place of the second, it was the mitral.

But by maturer observation it was found that this cancn
would not hold, and that mere coincidence of the murmur with
the point of time, belonging to the first or second natural sound
of the heart would not determine wliich valve was diseased.
When the murmur was in the place of the first sound the
disease indeed often turned out to be, where Laennec would
have it, in the aortic valve ; but just as often did it turn out to
be, where Laennec would not have it, in the mitral valve. And,
when the murmur held the place of the second sound, the
disease was always in the aortic valve, where it should never be,
and never in the mitral, where it should always be, according
to the canon of Laennec. Thus the right key was hitherto
plainly wanting to the interpretation of the whole matter.

At length there was good reason to believe that the right
key was furnished to us by the doctrine of regurgitation ; in
other words, by the general fact that, under certain conditions of
valvular disease, the blood is not only impeded in its course
onwards, but that it does, and must in part flow backwards.

Only consider for a moment the proper ofiice of the valves.
They are meant (as it were) to keep guard at the orifices of the
heart, and throw them wide open to the onward course of the
blood, and hold them close-barred against its refluent current.
But disease spoils their fitness sometimes for this office, and
sometimes for that. In one case it thickens their texture, and
hurts their pliancy, so that they cannot fall back and clear the
way as completely as they ought, but must leave checks and
hindrances when the passage should be entirely free. In another
case it shortens and puckers them, and alters their shape, so that
they never shut their orifices as they ought, but leave a chink
or an aj)erture when the passage should be entirely closed.

Thus whether the blood be forced onwards or backwards
through a narrow passage, a murmur will equally result. The
auscrdtatory sign will be wanting in neither case.

The following are among the prominent facts which sug-
gested, and taught, and established this doctrine of regurgitating
murmurs. And it must be owned, that they are sufficiently
puzzling and inapplicable upon any other theory.

22 CLINICAL MEDICINE. [lECT. II.

In numerous well- watched cases, where a single murmur,
constantly and uniformly coincident with the systole of the heart,
had heen heard during life, the valve at the entrance of the aorta,
and this valve only, was found diseased after death. Here the-
murmur marked the time of the blood passing onwards from
the ventricle into the aorta, through an orifice only half open,
which should be open altogether. This was no murmur of
regurgitation.

Aeain, in numerous cases, where a single murmur had been
heard during life, but constantly and uniforroly coincident with
the diastole and not with the systole of the heart, still this same
valve at the entrance of the aorta, and this valve only, was
found diseased after death, Here the murmur marked the time
of the blood recoiling hachcards from the aorta towards the
ventricle, and partially re-entering it through an orifice only
half-closed, which should be closed altogether. This was the
genuine murmur of regurgitation.

Acain in numerous cases, where two murmurs had been heard
during life, one coincident with the systole, the other with the
diastole of the heart, still this valve at the entrance of the aorta,
and this valve only, was found diseased after death. Of these
two murmurs, proceeding from one and the same orifice, the latter
was the genuine murmur of regurgitation, and not the former.

It appeared, then, that the aortic valve, in its states of
disease, was capable of becoming the seat of two murmurs, one
regurgitating and the other not ; of either separately in different
cases, or of both together in one and the same case.

Yet again, in numerous cases where a single murmur, con-
stantly and uniformly coincident with the systole of the heart, had
been heard during life, the mitral valve, and it alone, was found
diseased after death, while the aortic valve was perfectly healthy.

But how could this be explained ? In its natural course it
is during the diastole that the blood passes through the orifice
guarded by the mitral valve from the auricle into the ventricle.
Here, however, the mitral valve being diseased, the murmur
does not mark the time of the blood passing into the ventricle
by the mitral orifice, but the time of its passing from the
ventricle by the aortic orifice : yet there was no disease of the
aortic valve to cause it. The only material thing, capable of
producing it, was still the diseased mitral valve. But how

LECT. II.] ON HEART MURMURS. 23

could this produce it ? Even by admitting the regurgitation of
blood back into tlie auricle. And the very point of time, at
which the murmur takes place, marks this for the cause, and
this for the manner of its production.

The same systole of the ventricle which carries the blood
forwards into the aorta, without impediment and without a
murmur, where there is no disease, throws it back partially,
and with a murmur, into the auricle, through the half-closed
mitral orifice, which now admits its regurgitation.

It has been said that the aortic orifice of the heart may be
the scat of two murmurs, in consequence of disease of its valve ;
one systolic, from the blood in its direct course, the other
diastolic, from the blood during regurgitation. Either murmur
may occur alone in difierent cases, or both may occur together
in the same case. But it would almost seem that the mitral
orifice coidd be the seat of only one murmur, and that murmur
the systolic* Remember, the systolic murmur proceeding from
the mitral valve always implies regurgitation.

Yet the condition of disease in the mitral valve is often found
to be such as must have raised certain impediment to the
passage of blood from the auricle into the ventricle. Why,
then, is the murmur, which would indicate such impediment,
and which would be coincident with the diastole of the heart, a
thing not found in practice, when the mitral valve alone is
diseased ?

It is probable that, as in health, when the mitral orifice is
entirely free, the blood glides from the auricle into the ventricle
without any impelling force from behind ; so in disease, when
the orifice is narrowed, the resistance does not produce any
extraordinary efibrt on the part of the auricle to overcome it.
And thus in disease, as well as in health, through a narrow
passage as well as a free one, the onward current of blood from
auricle to ventricle is still without noise. That it is otherwise
with the regurgitating current through the same passage, and
that the murmur of the blood rushing backward from ventricle
to auricle should be often signally loud, must be owing to the
force of the ventricle now engaged in impelling it.

* The cases are so rare, in which either the diastolic murmur alone, or
the systolic and the diastolic murmurs together, can be fairly imputed to the
mitral valve, that they are a sort of clinical curiosity.

34 CLINICAL MEDICINE. [lECT. II.

Thus by listening to endocardial murmurs during life, and
noting the exact time at which they occur, whether synchro-
nously with the systole of the heart, or with its diastole, or with
both, and then by ascertaining the exact seat of disease within
the heart after death, physicians had arrived at a just explana-
tion of the way in which those murmurs are produced. They
saw such a mechanism, formed by disease of the several valves,
as being played upon by the blood during the vital movements
of the heart, must needs have given occasion to the murmurs
which they heard ; to the direct murmur in one case, to the
regurgitating murmur in another, and to both of them in a third.
Now this doctrine of valvular regurgitation, which brought
with it a clearer insight into the whole rationale of endocardial
murmurs, was jaathologically a great step in advance. But in
diagnosis it rather seemed a step backward ; for it undid much
of our former knowledge by convicting it of error. We were
constrained to give up much which we once believed from seeing
that it could not possibly be true. Our better pathology was
for the present sorely puzzling to our diagnosis.

When we heard a loud endocardial murmur during life
always accompanying the systole of the heart, and when we
often found after death the aortic valve diseased and the mitral
sound, and just as often the mitral valve diseased and the aortic
sound, our pathological notions were equally satisfied in either
case. In the former we acknowledged the sufficient cause of the
onicard murmur, in the latter the sufficient cause of the hachvard
murmur, and we acknowledged the systole of the ventricle
equally instrumental in producing both. But still we could
not tell which was y^hich. during life, or when the aortic, or when
the mitral valve was unsound. The same endocardial murmur,
at the same article of time in all cases, could not inform us
which it was in any.

But at length we seem to have made a nearer approach to
unravel these difficulties of diagnosis, and to discriminate the
exact seat of endocardial murmurs during life, as well as under-
stand the mechanism of their production. For this purpose,
however, there are more things to be taken into accoimt
respecting them than their mere coincidence in point of time
with the systole or diastole of the heart.

Besides this coincidence, two general facts have been put

LECT. II.] ON HEART MURMURS. 25

forward, as surer interpreters of endocardial murmurs, in givini^
them a more exact meaning-, and assigning- them to the parti-
cular orifice from which they proceed. The first fact is, that
endocardial murmurs are most plainly audible at that part of
the precordial region which is nearest to the orifice from which
they proceed. The second fact is, that endocardial murmurs
are conveyed sometimes in one direction and sometimes in
another, and that the orifice from which they proceed deter-
mines in each particular case what that direction shall be.

Of these two general facts, I am more sure of the second than
of the first, and have better proof of its practical use. But we
will briefly consider them both.

" A line drawn from the inferior margins of the third ribs
across the sternum passes through the pulmonic valves a little
to the left of the mesial line, and those of the aorta lie behind
them, but about half an inch lower down."*

" A horizontal line drawn through (along ?) the under edge
of the sterno-costal articulations of the fourth ribs will cut
across nearly the middle of the length of the mitral valve, when
drawn outwards and downwards by its tendinous chords and
columnoo carneoc, and pass about two or three lines above that
portion of the tricuspid which most nearly approaches it, the
latter valve lying underneath the sternum, and the former
immediately to its left."t

So much of the sternum as these lines include to the left of
the mesial line, and the space they indicate between the lower
margin of the third and the lower margin of the fourth sterno-
costal cartilages on the left side, may be taken to mark that
portion of the pra^cordial region, behind which lie all the orifices
of the heart and a good share of the valvular structures apper-
taining to them. Now, inasmuch as the several orifices are
found at the basis of their respective valves, the pulmonary and
aortic orifices must be lower than the first horizontal line, and
the tricuspid and mitral orifices must be higher than the second.
How nearly, then, must they all approach one another in the
mid-space between them both ! So nearly, that the mouth of
an ordinary- sized, stethoscope would surely cover them all
within the circle of an inch and half or less. Whichever orifice
* Hope, on Diseases of the Heart, p. 3.
t Joy, ill Library of Medicine, vol. iii. 258, in a note.

26 CLINICAL MEDICINE. [lECT. II.

of the heart be affected, we are sure to find the endocardial
murmur here or hereabout. And listening here and here only,
we cannot seo:reo:ate the murmur of one orifice from that of
another. What then, if " endocardial murmurs are most
plainly audible in that part of the prsccordial region which is
nearest to the orifice from which they proceed ! " This general
fact, taken alone, cannot help us much in determining which of
them is afiected in a particular case, when they all lie clustered
together at the same, or nearly at the same, part of the
prnocordial region.

But suppose we raise our ear, or the stethoscope, from this
exact spot, and shift it an inch or two higher or an inch or two
lower. Higher we may hear the endocardial murmur still, and
lower we may lose it altogether. Or higher we may lose it
altogether, and lower we may hear it still. Or both higher and
lower we may still distinctly hear it. By this procedure we are
following the endocardial murmur in the direction it takes after
it leaves the orifice from which it is propagated ; and we find
how various the direction is, upwards in one case, downwards in
another, and both upwards and downwards in a third. But still
it is the orifice, from which it is propagated, that gives the
murmur its particular direction ; and this (it is said) may be
taken for a general fact.

Accordingly, when the endocardial murmur is conveyed in
an upward direction, even above the basis of the heart, and still
along the course of the aorta, and further still, as sometimes
happens, along the subclavian and carotid arteries, the aortic
orifice is its point of departure, and the valve, there situated, is
the valve diseased. "When it is conveyed in a downward direc-
tion, and to the apex of the heart, the auriculo- ventricular orifice
is its point of departure, and the valve, there situated, is the
valve diseased. And when it is convoyed both in an upward
and downward direction, both in the course of the aorta, and to
the apex of the heart, then it has two points of departure, and
both the aortic and the mitral valves are diseased. Here the
murmur, which is one to the ear, may be two in fact. The two
are made one by being both synchronous with the systole of the
ventricle. In this case the murmur from the aortic orifice is
direct, and that from the mitral is regurgitating. Or the
murmurs thus conveyed in different directions, as they are two

LECT. ir.] ON HEART MURMURS. 27

in fact, may be two to the ear. But then one must bo synchro-
nous with the diastole, the other with the systole of the heart.
In tliat case the diastolic murmur comes almost always from the
aortic and the systolic from the mitral orifice ; and the diastolic
and aortic murmur is not direct but regurgitating, and the
systolic and mitral murmur is regurgitating still.

The general fact, that endocardial murmurs pass in certain
directions according to the seat of the valvular disease, has yet a
further interest and use. It helps us some way towards the
differential diagnosis of diseases of the same order of valves on
the two sides of the heart.

When the murmur, audible in the space between the two
horizontal lines above described, is conveyed upwards and
beyond the basis of the heart, the disease may be either of the
aortic or of the pulmonic valves. The direction that it takes
from this point must determine which of the two ; for it may
take more than one direction. When it is heard passing
upwards for the space of two inches, and between the second
and third ribs of the right side, then it is taking the course of
the aorta, and the disease is of the aortic valve ; and still more
surely, if it be heard in the carotid arteries. But when it is
heard passing upwards between the second and third ribs, not
of the right but of the left side, then it is taking the course of
the pulmonary artery, and the disease is of the pulmonic valve ;
and still more surely, if it be not at all heard at the same time
in the carotids.

I doubt whether it would bo possible to arrive at a differential
diagnosis of diseases of the mitral and tricuspid valves from any
ascertainable difference in the direction to which the murmur
originating from one or the other is conveyed.

It should be remarked, that valvular disease on the right side
of the heart alone is a most rare occurrence ; and that, when it
is found on both sides together, the disease on the left generally
so far outruns that on the right, as to have reached its acme
before the other has hardly begun. Hence, in the vast majority
of cases, valvular murmurs proceed from the left side exclu-
sively ; and, in the few cases, where they proceed from both,
those from the left will probably be so much the loudest as to
overpower those of the right. And in the still fewer cases,
where they proceed exclusively from the right, they are sub-

28 CLINICAL MEDICINE. [lECT. II.

mltted too rarely to our observation for us to be familiar with.
the peculiarities which belong to them. In truth, almost all
our knowledge of endocardial murmurs, proceeding from
valvular disease, is derived from our study of those which
appertain to the left side of the heart.

Finally, then, is the doctrine of valvular regurgitation, are
the notices of time marked by the systole and diastole of the
heart, is the fact of sounds being heard more plainly in one
part of the prECCordial region than another, or the fact of
sounds being conveyed in this or that direction within or
beyond the precordial region, forward or backward, with the
current of the blood ; are all these facts true and stable, and
general enough to hold the place of principles ? And, if they
be, will they bear to be taken, always and without reserve, as
the sure exponents of endocardial murmurs, so far as to fix the
valve or orifice of the heart from which they proceed ? I dare
not affirm so much. I do, indeed, still make use of them as
principles, but I am less peremptory about the certainty of
their application than I was a year or two ago. Often the
event has been just as they would indicate. But occasionally
it has been contrariwise ; and the exceptions I have not always
been able to explain without prejudice to the assumed prin-
cij)les.

But we should not be in a hurry to abandon such general
facts as these which have often led us right, because they have
sometimes seemed to lead us wrong. We should rather suspect
the occasional interference of counteracting circumstances,
which we do not yet understand. In the history of our pro-
fession we meet too often with things utterly worthless
capriciously taken up, but sometimes with things really valu-
able capriciously laid aside.

Among the conditions, which may possibly intervene to
turn endocardial murmurs from the direction in which the
disease of particular valves would tend to convey them, the
following may be mentioned :

1st. The presence within the chest, and exterior to the
heart, of substances having a more solid consistence than its
natural contents, such as morbid growths of various kinds, or
anourismal tumours, or condensed portions of lung. These are
able to conduct the abnormal murmurs, no less than the natural

LECT. II.] ON llEAliT MUKMUKS. • 29

sounds, of the heart, to a g-rcater distance, and in any direction,
according- to the place they occupy.

2dly. The enlarged capacity of the heart itself, wliich is
the most frequent consequence and concomitant of its diseased
valves. The large dilated heart spreads its sounds abroad
laterally. And thus, whether the murmur be traced in the
course of the aorta, or not at all above the basis of the heart, it
is often as loudly audible from mamma to mamma, and every
where in front of the chest below the fourth ribs, as in the
priTCordial region itself ; and often even far round towards the
left axilla.

odly. The mere loudness of the endocardial murmur. The
abnormal murmurs, as well as the natural sounds, of the heart,
arc heard to a greater distance in proportion to their mere
loudness, and that not only in the directions to which the
current of the blood conducts them, but in all directions.

Now, when these three conditions meet ; the loud endo-
cardial murmur, itself very widely audible, and the enlarged
heart, ready to spread it still further abroad, and some solid
substance within the chest ready, according to what its seat
may be, to conduct it in any new direction, no wonder that the
tendency of a diseased valve to convey and to restrict the same
murmur within a particular channel should be sometimes
counteracted and disturbed.

To these several conditions I may add a fourth, viz. a
peculiar quality of the endocardial murmur, giving it a high
musical note. Such a murmur will sometimes refuse to sufi'er
restriction to any certain space within the body. It will even
carry itself outwards and reach the ears of bystanders at a short
distance.

Touching endocardial murmurs, as the signs of endocardial
disease, there remain two more points to be considered. They
have been relied upon, not only for fixing its seat in this or
that orifice of the heart, but also for estimating its magnitude
and the amount of impediment raised by it to the passage of
blood, and for determining the Icind of structural change which
it has produced.

The popular notion seems to be, that the louder the murmur
the greater the disease, and the greater the amount of impedi-
ment.

30 CLINICAL MEDICINE. [lECT. II.

The truth, however, is, that the murmur becomes louder as
the disease and the impediment increase only up to a certain
point, and then, that it becomes less and less loud as they go
'on to increase beyond this point. Thus the disease and the
impediment still increasing may, and sometimes do, reach a
point at which the endocardial murmur ceases thenceforth, and
altogether, as long as life remains.

Two individvials of unsound heart died within a few days of
each other. I witnessed the symptoms of their disease during
life, and after death I saw what that disease actually was. In
both the right ventricle was dilated, and the left was dilated
and hvpertrophied ; and in both the mitral valve and the aortic
valve were diseased. But the valvular disease, and the impedi-
ment resulting from it, were far greater in one case than in ^he
other. In the one the auriculo- ventricular orifice was so nar-
rowed as only just to admit the little finger, and the aortic
orifice was only just not closed. In the other there remained
a tolerably free space for the passage of blood through both
orifices.

Now in the first case during life there was no endocardial
murmur at all ; while during life in the second there was a loud
bellows-murmur audible in the whole praecordial region, and
far on either side of it, and beyond it upwards in the course of
the aorta.

All this seems to admit of easy explanation. When endo-
cardial murmurs result from diseased valves, there are two
agents engaged in producing them, viz. the mechanical obstacle
which the blood encounters, and the blood itself. It is from
unusual vibrations among the particles of the blood that the
unusual sound immediately proceeds; but it is the obstacle
which sets the conflict agoing. Now the sound must be in
proportion to the vibration ; and the vibration is in proportion
to the amount of the obstacle and the quantity of blood and
the rate at which it circulates taken together. Thus the endo-
cardial murmur becomes louder and louder while the valvular
disease is upon the increase, as long as the heart by its increas-
ing thickness is still able to force a large current of blood
through a moderately contracted orifice. But the endocardial
murmur becomes fainter and fainter, and at length ceases alto-
gether, as the valvular disease, by its further increase, goes on

LECT. II. J ON IIE.VRT MURMURS. 31

still to narrow the orifice, and the ventricle with all its increas-
ing thickness can only force the blood through it in a more
and more slender stream.

Further, there is, or, rather, perhaps there was, a notion-
that endocardial murmurs have wonderful diagnostic secrets
wrapped up in their varieties of kind and quality ; and that all
those similitudes, which they are in different cases found to
bear to the sounds of the bellows, the saw, the rasp, the file, or
to whistling or cooing, were worth our serious study, inasmuch
as they severally denote the very land of structural change
which a diseased valve has undergone, whether it be converted
into cartilage or earthy matter, into matter hard or soft, or
rough or smooth. Experience, however, does not countenance
the belief, that the land of endocardial murmur follows the hind
of endocardial disease.

But upon what do the varieties of murmur which accom-
pany valvular disease really depend ? Go into the wards of
this hospital, where there are always numerous cases of diseased
heart ready for observation, and perhaps you will find three or
four or half a dozen patients, in whom the endocardial murmur
is strongly marked, and has those accompanying conditions
(you know what they are) which make it highly probable, not
only that the disease is valvular, but valvular disease of the
same orifice in them all. But the murmur will have as many
varieties as there are patients; yet it will be characteristically
endocardial in all, while it is different in each.

Then go into the museum, and scrutinise half a dozen
specimens of disease in a particular valve. Let it be the same
valve which you believe to be the seat of disease in the patients
whom you have been examining in the wards. In all the
specimens you will find the orifice to which the valve belongs
obviously narrowed, but so narrowed as to leave the stricture of
different size and different form in each. Thus the orifice will
have become a pipe or a funnel or a chink in the several cases.
In one it is direct, in another tortuous; in another it has a bar
drawn across it, and has two apertures; in another it has
several bars drawn across it, and is cribriform.

No wonder then will any longer remain, that in the wards
of the hospital the patients whom you believe to have the same
valve of the heart diseased should all present the characteristic

32 CLINICAL MEDICINE. [lECT. II.

endocardial murmur, but each a different variety of it. The
murmur, with its accompanying conditions, denotes the val-
vular impediment and the orifice it occupies, while its varieties
arise from the different sizes and shapes of the orifice through
which the blood has to pass, and the rate at which it passes.

Upon the whole, my persuasion is, that no practical good
has come from curiously naming, and noting, and multiplying
endocardial murmurs. The mere murmur can only tell me
whether it proceed from the inside or from the outside of the
heart. For more than this I cannot trust it. But in telling
me this, it tells that which I have no possible means of knowing
without it.

Having determined that the murmur is endocardial, and
proceeds from within the heart, if I desire to know, moreover,
whether it arise from valvular disease, and from valvular
disease on which side of the heart and at which orifice ; then
for this more exact diagnosis I must add to the mere endo-
cardial murmur a reckoning of the time at which it occurs, and
a reckoning too, of the space within the precordial region at
which it is chiefly heard, and of the direction in which it is
conveyed.

And if (what is most important of all) I aim at a diagnosis
of the endocardial disease in respect of its essence and nature,
then to the mere sound, and its time and its place and its
direction, I must add a reckoning of the actions and sufferings
of the constitution at large which precede it and attend upon
it. These, which are the highest considerations of all, are
reserved for their proper place.

In the mean time I would observe of the mere murmiir, that
nothing would be lost in propriety of language, and much
gained in simplicity, if the term endocardial were made to
include all its ordinary varieties which proceed from within the
heart, and were the single term in common use ; and if the
fantastic similitudes which have been mentioned were only now
and then employed to help us in describing something extra-
ordinary, it would be all the better.

LECT. III.] ENDOCARDIAL MURxMURS. S.'J

LECTURE III.

ENDOCARDIAL MURMURS CONTINUED. — THEIR ORIGIN FROM VAL-
VULAR DISEASE SOMETIMES DOUBTFUL. MAY PROCEED FROM

OTHER FORMS OF MECHANICAL IMPEDIMENT. DEFORMED

CHEST, EXTERNAL PRESSURE. ENDOCARDIAL MURMURS

SOMETIMES CONFOUNDED WITH THE MURMUR OF RESPIRATION.

A PECULIAR MURMUR, AKIN TO THE ENDOCARDIAL, A

FREQUENT CONCOMITANT OF PULMONARY C0NSU5IPTI0N. EN-
DOCARDIAL, ARTERIAL, AND VENOUS MURMURS, PROCEEDING

FROM IMPOVERISHED BLOOD. EXOCARDIAL MURMURS. — THEIR

SEAT THE PERICARDIUM. THEIR ONLY KNOWN CAUSE THE

FRICTION OF ITS SURFACES IN A STATE OF DISEASE.

If ever a single sign could be taken at all times to denote one
thing and one thing only, you might think perhaps it must be
the endocardial murmur to denote mechanical impediment from
valvular disease. The theory of its production by this cause is
very plain and intelligible ; and many a man's experience may
have run uniformly in confirmation of it in every instance,
without exception, which has fallen under his notice. But
still individual experience, be it ever so large, is not all expe-
rience ; and truths without exception are not the truths most
commonly met with in medicine.

There are cases of endocardial murmur in which valvular
disease is at least doubtful ; and cases of endocardial murmur
in which there is mechanical impediment but no valvular
disease ; and cases in which there is neither mechanical impedi-
ment nor valvular disease ; and there are cases, too, in which
the ear itself is apt to be deceived into the belief of a murmur
proceeding from the heart, when there is no such murmur
in fact.

Now it is unwise so to treat of any medical subject as if it
were complete. Yet nothing, it must be allowed, is more
useful than to give that order and arrangement to the many

34 CLINICAL MEDICINE. [lECT. III.

accordant facts of medicine into which, they naturally fall. But
still a place must be found for other facts, few in number,
which are really or apparently contradictory to the rest, or at
least do not altogether harmonise with them.

Here, then, I must find a place for some of the rare facts
just alluded to, which have fallen in my way, touching endo-
cardial murmurs. I will state them, and comment briefly
upon their pathological bearings and relations as I go along.

I occasionally^ find the endocardial murmur under circum-
stances unlike those usually attending it when it is the un-
doubted result of valvular injury, and yet it probably does
l^roceed from valvular injury nevertheless.

There are cases in which the murmur is not constantly
present. It comes and goes ; and the circumstances under
which it comes and goes are to interpret for us the nature of
the disease out of which it sjDrings.

This has sometimes occurred to my observation. The
patient has been sensible of uneasiness in the region of the
heart, and of occasional palpitation. Upon examination I have
found the impulse slightly in excess, and the sounds louder and
more diff'used than natural, and nothing more. But these are
the common accompaniments of nervous disorder ; and accord-
ingly I have been about to conclude the heart to be perfectlj^
Bound, and to dismiss my patient with the comfortable assu-
rance that such was my belief. For my further satisfaction,
however, I have made him walk briskly once or twice round
Ihe room, and then listening again, I have found the impulse
of the heart considerably augmented, and an unquestionable
murmur. A few minutes of quiet have moderated the impulse,
and stilled the murmur : but he has taken another turn round
the room, and both impulse and murmur have returned. And
thus has the murmur been audible on exertion, and inaudible
on repose, several times in a quarter of an hour.

Now here, where we can make the murmur come and go at
will, simply by augmenting and reducing the force of the
heart's action, it is reasonable to believe, that there may be a
mechanical obstacle at an orifice of the heart, but that it is of
small amount; not enough to cause the requisite degree of
vibration when the current of the blood is slow and imdis-
turbed, but quite enough when it is more rapid and forcible.

LECT. III.] ENDOCARDIAL MURMURS. 35

This view of the matter obtains some illustration from what
has fallen imder my observation in certain cases of rheumatic
endocarditis, where a perfect cure has ultimately taken place.
Here, before the endocardial murmur has ceased altogether,
there has often been a period during which it has been some-
times absent and sometimes present — absent during repose,
present on exertion. You will hardly yet be able to see the
force of this argument, in which I am anticipating a part of
our subject to which no allusion has hitherto been made ; but
you will see it and appreciate it hereafter.

Three or four cases have fallen under my notice where an
endocardial murmur has arisen for the first time a few days
before the patient's death. I have been quite sure that it has
not existed previously, and I have had no prior suspicion of
disease of the heart. In these cases the act of dying was slow
and lingering. And although the murmur was declared a few
days before death, it did not arise until the dissolution might
be said to have already begun. But unfortunately the oppor-
tunity has not been afibrded me of making inquiry into the
cause of this remarkable circumstance after death. I conjectured
that it might be owing to blood which had begun to coagulate
within the ventricle, or even to inflammation of the endo-
cardium, such inflammation (as we shall see) may take place at
the very going out of life, and deposit lymph.

The following case was kindly communicated to me by Dr.
Maclachlan of Chelsea Hospital : — "An in-pensioner, aged 61,
long affected with paralysis and other symptoms indicating
organic affection of the brain, became bed-ridden about a fort-
night before death. He lay in a lethargic semi-comatose state,
and had great difficulty both in comprehending and in answer-
ing questions. During the last week of his existence the
heart's action became inordinate, and both sounds were accom-
panied by a hriiit de soufflet audible only in the praecordial region.
He died on the 25th of January."

" On the 21st of the month, the following is the report I
made of the physical signs ; and, as they interested me much,
I made repeated examinations, at different hours, always with
the same result, the sounds varying in degree with unknown
circumstances.

*' Percussion unusually clear in the praecordial region ;

36 CLINICAL MEDICINE. [lECT. III.

lieart's action inordinate, but regular ; impulse seen as well as
heard. Both sounds are accompanied with a hniit de soufflet,
more intense with the first. There is a most peculiar^ short,
clear, abrupt barking sound occasionally heard, which has its
greatest intensity immediately behind the nipple, and extends
only a little way on either side of it. This sound bears a
remarkable resemblance to the yelping of a very young puppy
dog. It appears to commence with the first sound ; to be for
an instant, and then to cease immediately. When it is loudest,
it is easily heard with the ear a little removed from the end of
the stethoscope. There is no fremitus, and the bruits are not
audible in the larger arteries, or beyond the praecordial region.
The man appears to suffer no pain ; and pressure underneath
the ribs, in the direction of the heart, neither affects the
breathing nor jDroduces uneasiness. The pulse is small, soft,
and regular.

" Scarcely any change took place in these signs up to the
termination of the case, with this exception, that, as the heart's
action became more feeble, the peculiar yelping sound dimi-
nished in intensity and frequency.

" On examination, forty-eight hours after death, I found
nothing to account satisfactorily for the production of the
sound alluded to. The pericardium was, however, unusually
thin and dry, and contained much less than the usual quantity
of fluid, for it scarcely amounted to half a drachm. It was not
rough, nor did it present any evidence of inflammation. The
heart felt firm, was preternaturally small, and the left ventricle
presented a beautiful specimen of concentric hypertrophy, the
walls exceeding an inch in thickness, and the cavity scarcely
admitting an ordinary- sized nutmeg. The right ventricle was
in all respects natural, and the valves of all the cavities, as well
as of the arterial trunks, were sound."

Here, with the appearances after death to help me, I can
come to no reasonable explanation, how the endocardial murmur
was produced during life. The case is very striking in all its
circumstances, and well worth recording ; and the best place I
could find for it is this, where I am speaking of the endocardial
murmur, never heard before, being first noticed among the
symptoms of dissolution.

Can the heart, by the mere force of its contraction, produce

LECT. III.] ENDOCARDIAL MURMURS. 37

a murmur exactly resembling that which jji'occeds from Talvular
impediment ? Perhaps it can. A young woman, herself in
perfect health, nursed an infant, to whom she was greatly
attached, in an attack of hydrocephalus. The infant died, and
she was seized with yiolent hysterical emotion. I did not see
her until the nervous struggle had come to an end, and she was
lying in bed apparently free from present excitement. But the
heart was still contracting with excessive force, and with the
loudest possible bellows-murmur. The next day the heart was
beating quietly, and the murmur was gone.

It is (I believe) a rare thing in adults, but in children com-
mon enough, for an endocardial murmur, simulating valvular
disease, thus to arise from the mere force of the heart's con-
traction.

Again, I have found the endocardial murmur under circum-
stances in which it was assuredly owing to mechanical impedi-
ment encountered by the blood in its passage through the heart,
and where the nature of the impediment was obvious enough ;
but it was not valvular injury.

Strange things happen to the heart when the chest is
deformed. There is an end of our pretending now to calculate
what its condition may be by listening and feeling and per-
cussing. Its sounds and impulses and resonances, be they what
they may, are now worth nothing at all as guides to diagnosis.
The heart is dragged from its proper seat, and imprisoned in
some strange place, and perhaps turned almost topsy-turvy by
the encroachment of the vertebral column and the approxima-
tion of the ribs. And thus cramped in and hooped about with
bone, at every movement it gives a jar that may be felt, and a
sound that may be heard in every part of the chest. And this
sound, which is thus conveyed to a distance, is seldom the
natural sound ; but a loud whiz, the same in kind and the
loudest in degree, which belongs to mechanical impediment
from valvular disease. And mechanical impediment there is,
but valvular disease there is none. The weight and pressure,
which the heart or its large vessels sustain from the hard frame-
work of the chest, raise the impediment, and throw it in the
way of the circulating blood.

Here the cause from which the endocardial murmur pro-

38 CLINICAL MEDICINE. [lECT. III.

ceeds is without the heart, but unthin the body. It may be
both without the heart, and without the body.

A little boy, aged eight years and a half, high-spirited and
vivacious, but thin and out of health, was brought to me under
a suspicion of disease of the heart. Its impulse was not felt
beyond the apex, but there it was in excess ; yet there was no
larger space of dulness than natural in the prsecordial region.
Upon auscultation, however, this remarkable peculiarity was
made out. When the ear or the stethoscope rested gently
upon the praecordial region, no unnatural sound whatever was
heard. But when either the ear or the stethoscope was applied
with such force as to cause the ribs to sink a little below their
natural level, then a loud bellows-murmur sprang up. The
space at which it was heard, and not beyond it, was just so far
as the mouth of the stethoscope covered, when it was placed
upon the cartilage of the third rib as a centre. Below and
above this spot the murmur vanished, and it was audible
neither in the course of the aorta nor in the carotids.

This case, which occurred to me five years ago, has made
me watchful ever since, lest haply I might sometimes create the
murmur I was in search of. And it is no needless caution
where the patient is young and the frame-work of the chest is
yielding. Never, indeed, the chest being not deformed, never
but in this single instance, have I produced a murmur simulat-
ing that of valvular disease. But very often, when, over-
earnest in what I was about, I have pressed too heavily upon
the proccordial region, a sort of jarring sound has reached my
ear, and brought with it the susjDicion of disease, until setting
the heart free from the weight and the restraint which I had
inadvertently imposed upon it, I have at once lost the sound
and the apprehensions too, which had arisen from my own
awkward manoeuvring.

It is well to know this possible fallacy of our own making,
and so to guard against it.

But, though by pressure upon the praecordial region, I have
often produced some unusual sort of endocardial murmur, never
(as before stated), where the chest has been free from deformity,
have I produced the murmur exactly simulative of that which
belongs to valvular disease but in this one instance.

LECT. III.] ENDOCARDIAL MURMURS. 39

The cticken-Lrcast, which, scarcely passes for a deformitj',
is often sufficient greatly to alter the relation of the heart to the
walls of the chest. It often thrusts it forward, and brings its
whole anterior surface in contact with the sternum and ri1)s
Hence in such cases the question, whether the heart be sound
or unsound, becomes puzzling enough. Sound or unsound, its
impulse is to be felt and seen in all the space at which it lies in
contact with the chest, and the same space is dull to percussion.
Extensive precordial impulse and extensive proocordial dulness
are the very signs of hypertrophy ; and if to these be super-
added the endocardial murmur, j^ou have the complete signs
denoting the commonest form of complex unsoundness which
the heart is apt to imdergo, viz. hypertrophy with valvular
disease. But beware, now especially, beware, of creating the
endocardial murmur by the application of the ear or the
stethoscope to the precordial region. ^Nothing is easier. I
have done so frequently in such cases by way of experiment.

There is yet another possible fallacy imputing an endo-
cardial murmur, and with it the suspicion of disease to the
heart, where no such murmur and no such disease really exist.
Here, however, the fallacy is not of our own making, but
arises altogether from a perplexing coincidence of action
between the heart and the lungs.

It has been said that endocardial murmurs are best imi-
tated by modulations of the breathing and by help of the
mouth. Hence it is not to be wondered at that there should
be an endocardial murmur which nearly resembles the natural
murmur of respiration. The commonest of all the endocardial
varieties is the bellows-murmur ; and the natural murmur of
respiration is only a gentler sound of the same kind, but more
prolonged. Hence the morbid sound of the heart and the
natural sound of the lungs are sometimes so much alike, that,
if the systole of the ventricles and the act of inspiration kept
time with each other, it might not be easy to determine from
which of the two organs the murmur came.

And, in point of fact, I have sometimes listened and hesi-
tated, and hesitated and listened again and again, before
I could satisfy myself that a murmur which came altogether
from the lungs did not in part proceed from the heart
also. It has been carried with an impulse into the ear as if it

40 ' CLINICAL MEDICINE. [lECT. III.

came from the heart. The method of clearing up the doubt is
to auscult the heart, while the respiration is suspended for a
quarter of a minute.

I must here find a place for noting a certain auscultatory
phenomenon, which, though it may not have struck the general
observation, is frequent and familiar to my own, and has
gained an importance in my eyes from the pathological con-
ditions with which I have found it associated. To the ear it
claims kindred with endocardial murmurs. But althoucrh the
heart may be instrumental in producing it, it is not at all per-
ceived within the precordial region, but in a certain definite
and circumscribed space beyond it.

Fancy a line drawn from the left side of the sternum along
the upper edge of the second costal cartilage and continued an
inch along the second rib ; and another line drawn from the
sternum along the lower edge of the third costal cartilage and
continued an inch along the third rib. Between these two lines
a space is included, in the whole or in part of which a murmur
is often audible coincident with the systole of the heart, when
no such murmur can be perceived either in the pra3cordial
region, or in the course of the aorta, or in the carotids, or in
any part of the arterial system, but here and here only. It is
a gentle bellows-murmur, quite obvious to the ear and unmis-
takeable in its character.

Of such a murmur, often audible in this situation exclusively,
I am certain as a matter of fact, and certain too of its very
remarkable accompaniments. I have witnessed it either in
those who were undeniably consumptive, or in those who were
too justly suspected of being so. I cannot say in what pro-
portion of the phthisical it occurs ; but I am continually meeting
with it.

Yet my knowledge goes no farther than the living symp-
tom. I have gained no explanation of it by dissection : I have
only a clinical experience of the matter. But there is a
practical usefulness in the mere experience of coincident facts,
though their pathological relation be not yet understood. Thus,
where from my direct examination of the lungs I cannot get
beyond a suspicion of tubercular disease, the murmur in the
space indicated must always contribute to confirm it.

Supposing the pulmonary artery in its first divisions to be

LECT. III.] BLOOD MURMURS. 41

the seat of the murmur, does it become such in consequence of
its own disease or by reason of pressure or impediment reaching
it from diseased lung- ?

Thus far we have dwelt upon endocardial murmurs, as the
result of mechanical impediment to the circulation, real or sus-
pected ; real, when it proceeds from known valvular disease ;
suspected, when it proceeds from other causes which are less
surely ascertained. Moreover, we have noticed, by the way,
the possible fallacy in some cases of mistaking the respiratory
murmur of health for the endocardial murmur of disease.
And we have alluded to a murmur accompanying the systole of
the heart, and heard in a certain thoracic space, and remarkable
for its frequent coincidence with pulmonary consumption.

Certain endocardial murmurs yet remain to be noticed,
which are quite distinct jDathologically from all these. Syn-
chronous with the systole of the ventricles, audible in the praj-
cordial region, and extensively diffused through the arteries,
resembling the bellows-sound, and so having the commonest
quality of endocardial murmurs, not distinguishable by the
ear from those which proceed from mechanical impediment to
the passage of blood, yet themselves springing from a different
cause, they form a class by themselves, and a most important
class it is.

I allude to the cases in which there is an unnatural sound,
both endocardial and arterial, and yet no change of structure
in the heart and arteries, but a change in the relative propor-
tions of the constituent elements of the blood.

The one general fact with which the sound is constantly
associated is an impoverishment of the blood, or the state in
which its red globules are deficient and its serum is in excess.

Now this impoverishment of the blood would seem to stand
to the endocardial murmur in the relation of a cause from
observation of their constant coincidence merely; and much
more so, from the observation that, upon removal of the first,
the second always ceases. In proportion as under proper
medical treatment the blood becomes richer, and is made to
abound more in red globules, the murmur waxes fainter and
fainter in the heart and arteries, until it is finally altogether
inaudible in both.

But if this endocardial and arterial murmur be really

42 CLINICAL MEDICINE. [lECT. III.

owing to an impoverished state of the blood, one would expect
to find that the simple abstraction of blood to a large amount
would produce it at any time in a healthy person. And so it
will. "We are not indeed accustomed thus to bleed healthy
persons purelj^ for the sake of experiment. But healthy persons
sometimes become the subjects of such treatment in the case of
accidents and injuries, and in the first access of acute inflamma-
tion ; and then we take advantage of the occasion for learning
the effect of the experiment beyond the purpose for which it
was instituted. And so we find that, if in a healthy man we
carry bleeding far enough to blanch the surface of the body, we
create an audible systolic murmur in the pra)Cordial region, and
diffuse it through the arteries.

Now this murmur is prominently characteristic of certain
forms of disease : and, knowing how w^e can produce it at will,
we should expect to find nature producing it exactly or nearly
in the same way. Profuse or protracted monorrhagia, by the
time it has blanched the skin, has this murmur for its sure
accompaniment. Here is direct loss of blood. Chlorotic anjEmia
has the same. Here is no direct loss of blood, but, w^hat is tan-
tamount to it, a defect or failure of the assimilatory functions,
whence the mass of blood is not replenished in due projDortion to
its expenditure upon the uses of the economy.

Generally accompanying the endocardial and arterial mur-
mur, when it is owing to ansemia or an impoverished blood,
there is another soimd quite difierent in kind, and formed
neither in the heart nor in the arteries, but traceable to the
same pathological condition.

In following the murmur from the heart along the aorta and
the subclavian artery, and then above the clavicle, when you
reach the carotid you find a new sound superadded to it. You
perceive the bellows-murmur coming and going with distinct
whifis, and keeping time with the systole of the heart in the
neck as in the chest ; but in the neck you perceive, moreover, a
continuous hum, like that which reaches the ear from the hollow
of a marine shell. This is a thing so evident, that it was
noticed and described, and variously speculated upon by those,
who first practised auscultation. But their speculations were
wide of the mark. Whence or how it arose no one could tell,
until the sagacity of Dr. Ogier Ward traced it to the veins, and

LECT. III.] VENOUS MURMURS. 43

showed it to proceed from tlic movement of the blood within
them.*

The vein, which offers itself most readily to the application
of the stethoscope, and admits all the easy experiments which
serve to certify the fact, is the internal jugular. Place the
instrument upon the neck by the side of the trachea, and pretty
close to it, and at the same time rest your finger upon the space
between the angle of the jaw and the mastoid process ; and when
your ear has caught a continuous humming sound, and listened
for a while and made sure of it, then press your finger firmly
down upon the vein, and the sound, if it be the true venous
murmur, will immediately cease ; then raise your finger, and if
it be the true venous murmur, it will immediately return.

A little manao-ement and address are needed to find this
venous murmur, and then keep it within hearing when you
have found it. I have seen it found by accident, heard for a
minute, and then lost and never heard agaim The instrument
has been laid carelessly upon the neck and the murmur has
been audible immediately ; and then, in expectation of making
it heard to more advantage, the neck has been put upon the
stretch, the chin raised and the head thrown back, or turned far
round to the opposite side, whereupon the murmur has ceased.
Then the neck has been relaxed, the head brought forward, and
the chin inclined towards the sternum, but the murmur has not
returned. The truth is, a very free current of blood is essential
to the production of the venous murmur. A slight degree of
pressure upon the vein will alter its character, and pressure
very far short of that which would arrest the current of blood
will abolish it altogether. And thus the neck being put upon
the stretch, the muscles, which lie parallel with the vein and
across it, are made to exercise pressure enough upon it to
interfere with the free current of blood, and to ^top the sound :
or the neck being relaxed, the vein and the integuments get
folded together, and so pressure is produced in another way,
and this equally stops the sound. Try different degrees of
pressure upon the internal jugular vein with the stethoscope
when the venous murmur is distinctly audible, and you will find
how lightly you must hold the instrument to keep it constantly
within hearing, how inconsiderable an amount of pressure will

* Med. Gazette, vol. xx. p. 7.

44 CLINICAL MEDICINE. [lECT. III.

obliterate it, and how eacli degree short of that which obliterates
it will give it sundry varieties, and make it musical.

Now these murmurs, whether appertaining to the heart and
arteries or to the veins, which have their origin in the quality
of the blood that circulates within them, furnish an eminent
example of the highest degree of comprehensiveness both for
knowledge and for use, which can belong to the idea of a
symptom.

Where these murmurs are, there a countless variety of other
symptoms is found in company with them, pointing to all organs
of the body, and giving notice that the functions of all are going
wrong; the surface pale and cold, palpitation and dyspnoea,
appetite perverse, digestion imperfect, nutrition insufficient,
secretions scanty and unhealthy, pain everywhere, and a shat-
tered nervous system and an enfeebled brain. Such a portentous
crowd of symptoms strikes the observation at once. But what
they all mean, we cannot tell, until we take one single symptom
for their sole and sufficient interpreter. The murmur which is
at the same time endocardial and arterial and venous is com-
prehensive of them all, and includes the knowledge of them all,
inasmuch as it points directly to their one common source, even
the impoverished blood. And further, this same murmur not
only contains the knowledge of all the rest, but it is the single
representative of them all as an indication of treatment.
Standing, as it does, for the sign of impoverished blood, we
treat what it denotes, and nothing else. But in so doing we
treat inclusively every error of function throughout the body
which proceeds from it.

Such are endocardial murmurs, which have their origin and
seat and efficient causes within the heart, which are different in
kind from its natural and healthy sounds, and which take the
place of them.4 Their causes (as far as our present knowledge
has reached) may consist in unusual vibrations induced among
the particles of the blood either by mechanical obstacles which
it encounters in its passage, or (whether directly or indirectly)
by a change in its constituent elements, and quite independent
of such obstacles.

But there are also exocardial murmurs, of which the general
characteristics have been already given. These have their
origin and seat and efficient causes without the heart ; and.

LECT. III.] ENDOCAIiDIAL MURMURS. 45

while they are different in kind from its natural and healthy
sounds, they do not supersede them, or take their place, or
necessarily interfere with them in any way. They are formed
in the pericardium.

The lungs and the pleura, and the heart and the pericardium,
have many things which bear a resemblance or analogy, so far
as regards the murmurs resulting from them respectively in
their several diseases ; these may be now usefully adverted to
in illustration of that part of our subject at which we have
arrived.

Such is the structure of the lungs that they perform their
natural and healthy functions with certain perceptible sounds.
But such is the structure of the pleura that no perceptible
sound whatever attends its natural and healthy functions. The
pleural surfaces glide over each other in perfect silence, and
the ear can catch not the least notice of their contact and
movement in opposite directions. Hence this difference belongs
to the auscultatory signs arising from diseases of the lungs and
of the pleura respectively ; that in pulmonary diseases the
auscultatory signs consist of the natural sounds exaggerated or
diminished, or occasionally modified, as well as of new sounds,
whereas in pleural diseases, there being no natural sounds to be
exaggerated, diminished, or modified, the auscultatory signs
consist of new sounds alone.

The same may be said of the heart and the pericardium.
Take the heart apart from the pericardium, and it never moves
without a sound. Take the pericardium apart from^the heart,
and it never moves with one. Take the diseases of the heart
apart from those of the pericardium, and the auscultatory sounds
denoting them may consist of its natural sounds exaggerated,
diminished, or variously modified, or of sounds altogether new
in kind. Take the diseases of the pericardium apart from those
of the heart, and the auscultatory signs denoting them (since
the pericardium has no natural sounds capable of being exagge-
rated, diminished, or modified) must always consist of sounds
new in kind, and of such only.

Farther, the lungs and the heart have not only the elements
of their diseased murmurs contained in their natural sounds,
but it is by the same instrumental means that they bring out
both ; and these are the very instrumental means of their own

46 CLINICAL MEDICINE. [lECT. III.

vital functions. It is tlie air by wliich, and out of which, the
lungs effect their office of respiration ; and it is the air by which
they form the sounds which are the audible notices both of their
health and their disease. It is the blood by which, and for the
sake of which, the heart fulfils its office of circulation, and it is
the blood by which it makes its sounds of health and its mur-
murs of disease.

But it is otherwise with the pleura and the pericardium.
As there is no element of the to and fro sound discoverable in
health, so there are no instrumental means then in operation
out of which it could be formed. The pleura does not make its
attrition- sound by the respired air, or the pericardium its
attrition- sound by the circulating blood. But the instrumental
means of both are purely the creation of their diseases. These
consist of strange substances separated from the blood and
deposited upon the pleural surfaces, or the pericardial surfaces,
spoiling their natural smoothness and lubricity, interrupting
their noiseless play upon each other, and causing them to grate
together with a sound.

LECT. IV.] AUSCULTATION OF THE IIEAKT. 47

LECTUEE lY.

GENERAL ESTIMATE OF THE USES OF AUSCULTATION APPLIED TO

THE HEART.

What I have laid before you is the alphabet, or at most the
spelling-book, without which you will never be able to under-
stand the auscultatory language expressive of diseases of the
heart. And, until you know it, and know it well, j'^ou must go
on blundering and guessing as children do, until they have
learnt to read.

But to decipher the auscultatory language of diseases of
the heart easily and accurately is an affair requiring labour and
use and docility. If you find it a hard task, you most not
excuse yourselves upon the plea that this, that, and the other
man knew nothing about it, and yet they were esteemed wise
in their time ; or that many men, who now pass for wise, deride
it, or that many, who profess to understand it, make mistakes
about it or apply it to no good end.

Yet as the ability to read does not make a man literary or
learned, but only furnishes him the means, the indispensable
means, however, of becoming so, so neither does the skill to
decipher the auscultatory language of the heart make him all at
once a great pathologist or a good practitioner in respect of its
diseases ; but being constantly, soberly, and diligently applied,
it furnishes him with much help towards a surer knowledge
and a better treatment of them. For auscultation is conversant
with principles.

And above all things we should covet principles ; for most
certainly they do not abound in practical medicine. The
records of practical medicine are chiefly made up of the sagacity
of this man and the experience of that, of much that has been
luckily conceived or cleverly reasoned, and of some things that
have been concluded with a fair probability of truth. But in
all this sagacity and experience, in all that has been so conceived

48 CLINICAL MEDICINE. [lECT. IV.

and reasoned and concluded, there is wanting the test of prin-
ciples to tell us how much real truth is contained.

JN^ow, as the best men among us have ever felt the want of
principles to test the truth both of their own knowledge and
that of others, so they have been ever ready to accept them
whenever they have appeared. Whenever in medicine any
thing like a discovery has been made, any thing which has had
the show of a principle or a law, a large surrender of cherished
opinions has always followed, and knoAvledge has seemed to
begin its career afresh from a new starting place. Mr. Hunter's
work on the blood and inflammation abolished half the loiowledge
which the world had then to boast on these subjects. It showed
that there had never before been any such thing as a pathology
of local morbid processes. Abounding in principles, or in the
germs of principles, it afforded a point of departure for all future
study and observation, to the disregard of abundance of notions,
opinions, and reasonings previously accepted and allowed.

So in our own times auscultation has been a discovery in
th6 art of clinical observation, inasmuch as within a certain
sphere it has furnished us with principles really scientific for its
use and exercise ; consequently in regard to the diseases of those
organs to which auscultation is applicable^ almost all the pre-
vious records of clinical medicine have become useless. Our
inquiries now begin, and begin with certaint}^ from a new
starting point ; a point which, formerly, if they ever reached,
they only reached by conjecture.

For how then stood our knowledge of diseases of the heart
before auscultation came to illustrate them ? Truly by the
profession at large they were not much thought of or inquired
about until the commencement of the present century. Yet
Senac's was a great work, and the Epistles of Morgagni abound
in scattered information of great value upon this subject. A
good deal was known, but the knowledge was hidden knowledge.
It had not reached the general mind. Indeed the heart, in
respect of its pathology, seemed to lie out of the high road of
popular interest, until Corvisart wrote.

The treatise of Corvisart, when I was a student, was in all
our hands. And it well deserved to be ; for in it there was
knowledge of the best kind displayed in the best manner.
Taking what information he thought valuable from the works of

LECT. IV.] AUSCULTATION OF THE HEART. 49

others, and blending it with his own special experience, he
brought the whole to bear upon the pathology and clinical
diagnosis of diseases of the heart. Thus the entire subject may bo
said to have been first brought out of obscurity, and first placed
fairly Avithin our reach, by the clear and vigorous and methodical
and popular manner in which it was handled by the genius of
Corvisart. I do not believe it possible that the diagnosis of
diseases of the heart could ever have been carried beyond the
point to which Corvisart brought it (yet how far was it from
certain ?) by anything less than some new discovery in the art
of clinical observation.

That discovery has been made which we possess in auscul-
tation. Thus many forms of structural disorganisation and
disease belonging to the heart, which after much time and much
calculation of circumstances near and remote, and much cautious
reasoning, could heretofore be only plausibly and probably con-
jectured during the life of the patient, are now known at once and
infallibly attested by the ear. But the ear must be a well-educated
and well-practised ear, or it is not a trustworthy witness.
Remember this: for the knowledge of the senses is the best
knowledge ; but delusions of the senses are the worst delusions.
And men are as often deceived by their ears as by their eyes ;
and they may hear ghosts as well as see them.

But it is needless to dwell upon the indisputable fact, that
by the use of a well-discipKned and well-practised ear we arrive
at a readier and surer diagnosis of diseases of the heart than by
all the other means of inquiry which clinical observation can
command. Still we shoidd be careful to form a right estimate
of auscultation ; to value it for what it is worth and not for
what it is not. There is much indifierent taste and Averse judg-
ment in the Avorld, which are apt to applaud in the Avrong place,
and so to injure many things really good by their undiscerning
patronage of them. Auscultation has suffered in this way from
its friends ; and therefore I think it worth while to try and set
it right with the world, not concealing its weak points Avhile I
endeavour to do justice to its strong ones. I am speaking of
auscultation only respective to the heart.

The age we live in cannot be better characterised, as to ^the
manner in Avhich medicine has been studied and pursued in it,
than as the age of morbid anatomy. Almost the only instrument

4

50 CLINICAL MEDICINE. [lECT. IV.

of pathological research has been the scalpel. Now, that great
good has resulted from morbid anatomy it woidd be unjust to
deny. But this good there is a tendency to exaggerate ; and,
such as it really is, it has certainly fallen short of what might
have been anticipated from the universal study of almost half
a century. At length it has now confessedly done its best; and
all great improvements in medicine pathologically or practically
must henceforth be looked for not from morbid anatomy but
from other sources.

So far as morbid anatomy contemplates the late or last results
of disease which are fixed and irremediable and unalterable, its
value is very small. But so far as morbid anatomy contem-
plates disease in jjrogress, and scrutinises and explains its organic
processes, its value is very great.

Now the objects of morbid anatomy are the same with which
auscultation is peculiarly conversant in the organs to which it
reaches. And auscultation must have its value estimated in
proportion to these objects, be it less or be it more. When
during life it announces, even with infallible certainty, the late
or latest results of disease, now become fixed, irremediable, and
unalterable, auscultation is at its lowest estimation. When
during life it declares with equal certainty the existence of
disease while it is yet active, progressive, and remediable, auscul-
tation is at its highest value.

Of the diseases of the heart which afiect its structure and are
equally the objects of morbid anatomy and of auscultation, the
great majority are tardy and secret in their growth, and by the
time they are so far developed as to disclose themselves to our
clinical research they have already passed beyond the reach of
our remedies. They are no sooner known to exist than they
are known to be incurable. Already they bear the character
of results, not of operations. Atrophy and hypertroj)hy of its
muscular substance, and dilatation of its cavities, cartilaginous
thickening and ossification of its valves — these are the forms of
disease or disorganisation of the heart which crowd upon us in
hospitals, and are submitted to us in private,'^ to say what they
are, and how to cure them.

And indeed by helj) of auscultation we can say what they
are, but cure them we cannot. While they reveal themselves
almost infallibly to the ear, they are absolutely beyond the reach

LECT. IV.] AUSCULTATION OF THE HEART. 51

of any restorative power wliich cither belongs to the body spon-
taneously, or is capable of being called into exercise by art.
Their clinical diagnosis is indeed wonderfully complete and
beautiful ; and the ability of forming it which proceeds from a well
instructed ear, would, upon each occasion of its success deserve
to claim a sort of triumph, if success were not very common.

For a long time, after most physicians of common sense had
accepted auscultation, and allowed its use, and most physicians
of moderate experience had gained some familiarity with its
jjractice, its application to the heart was only known in cases of
its fixed, unalterable, and irremediable disorganisations ; and of
these it certified the existence, and this was all. But there is
nothing so captivating as new knowledge. Even though its
subject be incurable diseases, which it renders not a whit the
less incurable, still it is captivating. Hence the extraordinary
interest with which auscultation invested these incurable diseases
■of the heart, simply by making us sure of their existence.

Cases of such diseases always abounded in hospitals. They
were essentially difficult cases. Their symptoms were hard to
interpret into any definite meaning. They betokened that in
some way or other the heart was diseased, and that in some way
or other their sure termination was death. Day by day to
watch over these cases and to treat them was an irksome duty
— it was even a thing to damp the spirits.

But auscultation brought to them a new light and a new
interest. And then these same became the cases which we were
continually busy about, which we were never tired of visiting
and examining and ausculting, and of examining and ausculting
again and again; and so comparing our clinical observation
during life with the disclosures of morbid anatomy after death
, we became vain of our often-verified diagnosis.

Nay, we were not only captivated with, but we almost made
a plaything of, our new knowledge. Every variety of sounds
arising from the heart which the ear could catch and dis-
criminate acquired a fimciful importance; and attempts were
made to signify them by apt similitudes, and even to express
them by musical notes.

But no man who rightly estimates the ends of knowledge could
rest in this and be satisfied ; for this would be to value what he
knows, not by its fruits, but by his own satisfaction in knowing it.

52 CLINICAL MEDICINE. [lECT. lY.

Thus far then in respect of the heart auscultation had taught
us a surer and more exact acquaintance with many diseases which
still we could not cure. The physician had become wiser, but
the patient had profited little.

But there is such a thing as having knowledge in reserve ;
such a thing as cherishing and increasing and perfecting it-
in hope, and looking patiently forward that the time may come
when mankind shall be the better for it.

It was in this spirit that the more sober-minded of medical
men at first, and for a long time, continued to exercise auscul-
tation in its application to the heart. Full of interest about it,
they were ever improving their skill in it, and ever learning
from it all that it was yet able to teach. But they held their
new knowledge not as a boast, but as an encouragement,
believing that there was a sealed-up treasure of usefulness
within it, which they should one day penetrate and disclose.

Yet time went on : and still auscultation only told us of
mischief when it was done, not of mischief while it was adoing.
Still it found a place only for the remedy which could render
what viust be borne more tolerable, not for the remedy which
could come in aid of counteraction and reparation and restoration
to health. Then, looking upon the purely mechanical nature of
the abnormal sounds of the heart, and at the mechanical way in
which they are formed, one might be pardoned for beginning
to doubt whether they would ever gain a high A-^alue among
the signs of diseases whose phenomena are pre-eminently vital ;
of diseases, which have pain ' and fever and nervous irritation
for their prominent ingredients ; and whether they would ever
help us better to understand and better to manage those
diseases, which to know early is alone to know profitably, and-
to treat early is alone to treat successfully ; whether, in short,
they would ever be available for diagnosis and practice in the-
acute inflammations of the heart.

Again, one might be pardoned for suspecting, from their very
nature, that the structural injury of the heart capable of pro-
ducing auscultatory signs must be always of large amount, and
the growth of long time, and that thus those signs would be-
found in the end to annex themselves solely to its chronic
diseases.

Time still went on ; and those who held the keys of know-

LECT. IV.] AUSCULTATION OF THE HEART. 53

ledg-e in this (^roat experiment, tlio physicians of hospitals, and
who had the fit objects and opportunities ever at hand for
proving and applying this new discovery in the art of clinical
observation, were still continually aiming- it, and pointing it at
the same mark, viz. at the attainment of a greater practical
benefit. And at length the mark has been hit, and the prize
has been won. For now there is no truth experimentally more
■certain than this, that auscultatory signs above all others, and
oftentimes before all others, and oftentimes in the place of all
■others, may be safely trusted to declare the beginning and the
augment, the decline and the cessation of acute inflammation in
those structures of the heart, which are especially, if not solely,
obnoxious to it ; and that the same signs may be confidently
appealed to as guides, by Avhich to choose the remedy, and
apportion its quantity and regulate its force, and continue or
discontinue its application.

A great amount of structural mischief (it appears) is not
needed to jDroduce in the heart an unwonted sound. As with
the more delicate pieces of machinery the least injury will
produce a jar, so with the heart ; and as with them this jar is
often the first notice of something wrong, so with the heart ;
and as in them the ear will often at once detect whether the
fault be of a wheel, of a screw, or a spring, so in the heart it
will at once tell whether the disease be of the membrane which
invests it without, or the membrane which lines it within.

Let it then be borne in mind, that the diseases and disorgani-
sations of the heart, which auscultation reveals to us during the
life of the patient, are of two classes. The one includes those
which are perceptibly progressive from day to day, and in which
we contemplate a present moving energy and operation. The
other includes those which are stationary, and in which we
contemplate a fixed and permanent result.

Now it is upon the first class of affections of the heart that
I shall principally dwell ; because they are those of which there
is a less familiar knowledge in the world, and therefore more
need of information, and because from the newness of their
matter they have a greater interest ; but above all, because they
are really and practically the most important. For the danger
to life with which they are charged is great,, and great, too, is
the danger of permanent injury to the organ if life be saved;

54 CLINICAL MEDICINE. [lECT. IV.

SO that all the extreme vig'ilaiice of time and opportunity which
we can bestow^ and many of the most powerful remedies which,
■medicine can furnish, are needed to save life and to save the
organ. Besides, these are the affections of the heart which
more than others seem to belong to it as its own by a strict and
peculiar, though not quite exclusive, appropriation. For in
them, except where it is occasionally shared by the lungs, the
whole force of morbid action is expended upon the heart. In.
them, except where the mischief occasionally reaches the lungs
also, life is perilled or destroyed by the magnitude of the injury
done to the heart ; and in them, except where some part of it
is occasionally called for by the lungs, the entire strength of
the remedy is brought to bear directly upon the heart ; well
therefore may they demand the most careful inquiry which we
can give them.

Upon the second class of affections of the heart, those which
are secret and chronic in their growth and unalterable and
irremediable in their nature, I shall content myself with a more
general commentary. Indeed, for the sake of practical utility,
this part of the subject needs rather to be comj^ressed than
enlarged. It is difficult to say what is its natural limit : it runs
out into so many subjects beyond itself, that if they were all
pursued they would lead us a ramble over the whole field of
pathology and practice.

After auscultation has taught all that can be learnt concern-
ing these affections as inherent in the heart, their exact seat,
and the exact nature of the mechanical change of structure in
which they consist, there is an end of all our concern with them.
as such. JSTo treatment follows. The injury done cannot be
undone. We have most probably made a correct diagnosis.
It is a poor boast indeed ; but it would be hard to grudge us the
little satisfaction (it is all we claim) of having done so.

Whatever objects of further interest belong in any way to
these cases, whatever objects of medical treatment there are in.
any way connected with them, must be sought and found out of
the heart itself and beyond it. But in most of these cases it is
not what we hear with our ears, it is not the injury suffered by
the heart that directly kills. Doubtless, if we could remove it^
the patient would be well ; but though we cannot remove it,,
much more must be added to it before he dies. For out of it

LECT. IV.] AUSCULTATION OF THE HEART. 55

is apt to spring every kind of disease wliich can be formed by
blood and blood-vessels in all parts of the body; congestions
and effusions, hemorrhages and inflammations, cerebral or pul-
monary, renal or hepatic. These constitute diseases of various
character and various name, according to the organ or the
function which they damage or destroy. Now it is of some of
these that the man whose heart-disease is of chronic growth
commonly dies ; and these are the objects of medical treatment
— objects for anticipation, for postponement, for mitigation, and
for temporary cure.

Concerning auscultation, then, in its application to the
heart, our inquiry hitherto has embraced the nature of its signs
and symbols, and what they are in themselves, and how they
are formed, and what they directly indicate ; also the certainty
of their use in the discovery of diseases of this organ during
life, and the extent to which clinical observation has profited
by them, and wherein, according to our present knowledge,
consists their greatest practical value, and wherein their least.

We will now j)roceed to pursue the subject in its practical
details, when much of what I have stated generally will be more
clearly seen and acloiowledged ; this indeed, and much besides,
which cannot in this place be intelligibly explained, viz. that
auscultation has actually disclosed to our knowledge by far the
most important portion of the entire pathology of the heart.
Before I enter into these details, I wish to say a few words, by
way of excusing myself to those who may find fault with me
for many omissions, and altogether far too much conciseness in.
handling so large a subject as diseases of the heart.

There are subjects in medicine about which the information
of various kinds to be found in books is enormous ; and if you
would learn all about them that is known or surmised, all that
is settled or is yet in controversy, you must go throvigh abundance
of reading, and have abundance of leisure, that so by thought
and meditation you may make all that you read your own.

But many of these subjects are practical subjects. Yet,
extensive and difficult as they are, there are men whom duty
and conscience require to have such a knowledge of them as they
can use readily and profitably every day of their lives ; and
such a knowledge, doubtless, many do possess ; and surely, you
may fancy, this must be a perfect knowledge ; but perfect, as

56 CLINICAL MEDICINE. [lECT. IV.

including every thing that belongs to the subject, it certainly is
not, perfect in its uses it may be.

The truth is, the knowledge which rules and regulates
practice, and which best insures its success, is commonly a
selected knowledge. It is also a knowledge which is compressed
and compendious in its form and compass, and so always manage-
able and always ready for using, and made to him who holds it
surer and surer by daily trial and experiment.

Now upon the subject of the heart and its diseases, what
knowledge I have to impart to you must be a selected knowledge ;
for passing by what to me, at least, is less certain and less stable,
I shall be content to dwell upon what from experience is best
understood by myself, and is likely to be most useful to you.
Here is a great hospital ; and here I hold that all teaching by
lectures should have for its first and principal purpose to give
effect to that self-teaching, which, from the objects which sur-
round us, all may practise and profit by who have eyes and ears
and a docile mind. Do not believe a word that I say until you
have gone into the wards and proved it. There you will find
your great book of instruction. I onlj^ pretend to su23ply a key,
a glossar}', or an index to it. Use that book as jow. ought, and
then, though in the end you and I may have the same knowledge,
it will not be because it has passed from my mind to yours, but,
being gained by your own observation, ratified by 3'our own
proofs, and matured by your own thought, you will have it and
hold it as your own independent possession.

LECT. v.] ENDOCARDITIS. • 57

LECTURE Y.

INFLAMMATION OF THE HEART. ENDOCARDITIS AND TERICAR-

DITIS. THE ENDOCARDIAL AND EXOCARDIAL MURMURS THEIR

CHIEF DIAGNOSTIC SIGNS. HOW THEY BECOME SUCH.

THE ENDOCARDIAL MURMUR, THOUGH FOUND IN NUMEROUS
OTHER DISEASES OF THE HEART, YET CONDITIONALLY THE

SURE SIGN OF ENDOCARDITIS. THE CLINICAL KNOWLEDGE

OF ENDOCARDITIS A NEW KNOWLEDGE. ITS CONNECTION

WITH ACUTE RHEUMATISM. HOW IT CAME TO BE DIS-
TINGUISHED, DURING LIFE, FROM FERICARDITIS.

We proceed next to consider the diseases of the heart clinically ;
and, first, its inflammations. These, as far as we know, have
their local origin and seat almost exclusively in the endocardial
and pericardial membranes.

Now the entire clinical history of endocarditis, or pericar-
ditis, viewed in all its details, is a very large and a very intricate
subject ; too large and too intricate to be made intelligible, unless
it can be greatlj" abridged and simplified. But how to abridge
and simplify it, and yet do neither wrong nor prejudice to any
substantial truth, is a difficult matter.

For this purpose I shall set up one pre-eminent sign for
each disease, and direct my course by it. And thus the clinical
history which I shall give of each will be little more than a
commentary upon its one pre-eminent sign, and the time and
conditions of its appearing, continuing, and ceasing ; while I
shall regard other signs, many or few, constant or occasional,
coming or going, as subordinate to it.

The pre-eminent sign of endocarditis is the endocardial
murmur, and of pericarditis the exccardial. But a clear notion
must be had how they become such before we advance a step
further.

The abnormal sounds or murmurs of the heart in their

58 CLINICAL MEDICINE. [lECT. V.

primary signification are, for the most part, tlie immediate
result of causes merely mechanical, the jarring and creaking
and grating of a piece of machinery that is out of order ; and
in learning whence and how they are produced, we learn at the
same time what part of the machinery it is that has suffered injury.

But it is a vital piece of machinery this with which we
have to do ; and the injury that makes it jar and creak and
grate is the product of vital processes, of an unhealthy kind,
which are, or have been, at work within it. Thus, in learning
the mechanism of the heart's abnormal sounds we learn some-
thing of its diseases — we learn their seat.

This is the first piece of knowledge that comes to us from
the study of the heart's abnormal sounds, the diagnosis of the
heart's diseases in respect of their seat ; and from the study ol
them and them alone this diagnosis may reach an extraordinary
accuracy. Yet still it is a diagnosis only of their seat ; and to
rate it at any high value would be ridiculous^ if it led to nothing
beyond itself.

But besides the seat of its disease, there is their nature, their
origin, their progress, their events, their treatment to be
inquired into. These are great heights of knowledge, and we
must in some way contrive to reach them. Yet how can the
theory of its abnormal sounds, when best understood, possibly
help us? At first sight it appears as the lowest round of a
ladder, the step just off the ground, upon Avhich, when a man
has duly secured his footing, he seems at a disheartening dis-
tance from the top.

Weil, then, how comes the endocardial murmur to be the
pre-eminent sign of endocarditis, and the exocardial of peri-
carditis, for neither one nor the other has an}- thing to do with
inflammation in its essence, or with the vital inflammatory
process as such? They have only to do with the products of
inflammation and the peculiar mechanical effects resulting from
them in the situations where they are now found. Thus they
become diagnostic of inflammation, not absolutely, but con-
currently with other signs and with certain joresent states and
conditions of the constitution at large.

The endocardium becomes rough and rugged from various
causes, and from inflammation among the rest ; and the j)eri-
cardium becomes rough and rugged from inflammation, and

LECT. v.] ENDOCARDITIS. 59

scarcely (us far as I know) from any (;aiisc beside. Bui, from
Avliatever cause tliey become such, the endocardial murmur will
luive the same character in one case, and the cxocardial the
same character in the other. For in both cases the murmurs
alone testify to the rough and rugged surface, and nothing-
more. But then the whole constitution is in a state of fever,
and when the present disease, which it suffers, is such as has
endocarditis or pericarditis for its frequent accompaniment,
then should either of the murmurs, not heard before, all at
once arise, it would proclaim inflammation of that membrane,
to which it j)ointed, without a doubt.

Thus, though the murmur alone would not mean endo-
carditis or pericarditis, yet all other symptoms put together
would not be enough to make us sure of either one or the other
■irltJiout the murmur. But n-ith the murmur a "very few are
sufficient to stamp the certainty of cither.

Bearing these considerations in mind, we are prepared to enter
upon the clinical history of these two inflammations with these
two murmurs for our guide. We will take endocarditis first.

( )f all auscultatory signs belonging to the heart, the endo-
cardial murmur occurs the oftenest, and includes the most.
It may result from any kind of injury sustained by the internal
lining or valvular structure of the heart, which can raise an
impediment to the passage of blood. It may result from any
kind of force, within the body or without the body, yet exterior
to the heart, which is so brought to bear upon it as to compress
its cavities. Such are spinal curvatures and foreign growths
within the chest ; and such is any thing of Aveight, or bulk, or
active power, applied upon the prtccordial region, sufficient ta
cause the sternum or the ribs to yield. And it may result from
the altered quality of the blood, from anaemia.

Now there are always within the hospital numerous ex-
amples of the endocardial murmur. Perhaps at this moment
you might here find cases showing severally each of the speci-
fied modes in which it is capable of being produced. SucK
ready opportunities of comparing and contrasting things appa-
rently the same, and so arriving more surely at the truth, may
not always be within your reach. Therefore you should make
the best of them while they are so.

In studying these cases you must not expect to find the

60 CLINICAL 3IEDICINE. [lECT. V.

endocardial murmur its own sufficient interpreter. From simply
listening to the murmur, and asking no questions, you will not
be able to tell what it means. In the man, who a few days ago
was seized with fever, being then in perfect health, it means
one thing; in the man, who has been out of health for years
and has been long suffering dj^spnoea and palpitation, it means
another; in the man deformed from his birth, another; and in
the pale chlorotic girl, with the feeble, frequent, jerking pulse,
it means another. Yet it is the same kind of murmur, the
murmur simidating the sound of bellows, in all; and being the
same, it cannot entirely explain itself — it cannot be its own
interpreter. It requires aid from concomitant circumstances to
decide its meaning in each particular case. The aid it needs is
often very little ; but that little it must have, and then it teUs
its story clearly and explicitly.

Should it happen, when great heat and nervous excitement
had been newly developed throughout the bod}^ and when
actual inflammation had recently become visible on external
parts; should it happen that the endocardial murmur, well
known never to have been present before, then arose for the
first time; assuredly it would at once fix the seat of disease in
the endocardium, and determine that disease to be recent and acute
inflammation. Though there might yet be no pain, no palpita-
tion, no direct symptom whatever referrible to the heart but the
endocardial murmur alone, yet it alone wouldbe enough to fix the
seat, and, imder the circumstances, the nature of the disease.

Truth in all its kinds is most difl[icidt to win ; and truth in
medicine is the most difiicult of all. And here is the proof of
it. This acute inflammation of the endocardium, this endocar-
ditis, has been (I will not say) altogether unknown to me, but
unknown in its real extent and frequency during two-thirds of
my professional life.

Morbid Anatomy had sought for it, but had sought at
random, and so had only found it once or twice by chance. It
had put a few cases upon record, showing that such and such
were the appearances which characterised this rare disease,
when it happened to occur. And clinical observation was
equally in the dark : it had stumbled upon it now and then by
accident ; but when or where to look for it, or by what signs
to recognise it, it could not tell.

LFXT. v.] ENDOCARDITIS. 61

JS^ow clinical observation, tliougli never blind, was, until
lately, always deaf. Yet there were always many diseases
which during the life of the patient spoke only to the ear.
These could never have been known, or could only have been
guessed at, until clinical observation learnt the use and exercise
of that sense by which alone they are discerned.

Hence Auscultation has had the effect of making it appear
that rare diseases have all at once become strangely multiplied,
whereas it has only disclosed what was before hidden, and made
that the subject of sure diagnosis which was before hit upon by
chance.

Endocarditis is one of those apparently new diseases ; and
it will be interestin"- to trace in what manner our knowled^'o
and sure diagnosis of it is due to Auscultation.

Endocarditis is at present chiefly known as a concomitant of
Acute Ilheumatism.

In the year 1826 I was the first to teach the students of
this hospital the fact, that whenever the heart was affected in
acute rheumatism, a sound different from the sound of health
always accompanied its contraction. This was then a new fact,
and one of immense importance ; and all succeeding observation
has gone to confirm its truth. This sound in the vast majority
of instances was the bellows' murmur. I must not call it
endocardial, for it was not yet known to be so. But in some,
instead of the bellows' murmur, it was some strange sound
difficult to describe; and in others this strange indescribable
sound and the bellows' murmur seemed to occur together: there
was a mixture of both.

My notion then was, that all these sounds arose in some way
or other out of inflammation of the pericardium ; and taking
them all, severally and in combination, as the signs of pericar-
ditis, I was amazed to find how far the frequency of its occur-
rence in acute rheumatism exceeded the common calculation.
and belief.

In process of time I found, upon a comparison of cases,,
that where in acute rheumatism the bellows' murmur occurred
alone, the affection of the heart was upon the whole far less
severe and far less perilous to life, than where some other
unnatural sound occurred alone or in combination with it. I
observed, too, that in some cases where the bellows' murmur was

62 CLINICAL MEDICINE. LECT. V.

unequivocal, the patient betrayed no uneasiness, no palpitation,
in short, no other symptom which could give the least suspicion
of a diseased heart ; yet that in the great majority of instances
where it once existed it remained permanent as long as the
patient continued under my care and observation.

At length I began to doubt whether the bellows' murmur
arising in the course of acute rheumatism was really derived
from the pericardium, and to suspect that it proceeded from the
internal lining. But for years the practice of this great hos-
pital did not afford me a single opjDortimity of resolving my
doubt, or of confirming my conjecture. For of that disease of
the heart, which, coming on during acute rheumatism, is
characterised by the bellows' murmur, no patient of mine ever
died, and I could learn nothing about it from dissection. But
what my own experience would not furnish, M. Bouillaud's
has supplied. Many have died during the active progress of
this disease imder his care, and dissection has found it to be
inflammation of the endocardium. Thus we are indebted to
M. Bouillaud for our first knowledge of this important fact.

Nearly about the same time Dr. "Watson and Dr. Stokes, of
Dublin, further illustrated this important subject by separating
those of her sounds of the heart, which I have mentioned to occur
in acute rheumatism, from the bellows' murmur, and analysing
them apart. These they found to possess the character of attri-
tion, as if produced by surfaces moving to and fro upon each
other, and traced them home to their local origin in the peri-
cardium, and showed the condition of their production to be a
defective lubricity, or a ruggedness and unevenness of that
membrane, such as would result from inflammation. In short,
they showed these to be the proper signs of pericarditis, as the
bellows' murmur is of endocarditis ; that, when in acute rheuma-
tism either occurs alone (as it often does), the disease is simple
pericarditis, or simple endocarditis ; and that when in acute
rheumatism both occur together (as they often do), there is a
mixture of the two diseases in the same subject.

The bellows' murmur coming on in the course of acute
rheumatism is a sure sign of inflammation of the endocardium.
Here, then, we will drop this exceedingly vulgar name, and call
it " endocardial" again. But observe, it is the general character
of the morbid actions predominant in the system at large which

LECT. v.] ENDOCARDITIS. 63

determines the pcarticular character of the local disease out of
which the endocardial murmur arises. They are inflammatory,
and it is inflammation.

In endocarditis, besides the endocardial murmur, there may
be other symptoms present directly refcrrible to the heart, or
there may not. There may or may not be pain. There may
or may not be an excessive impulse, or an intermittent, irregu-
lar, or fluttering action of the heart. But the fact of
endocarditis is not rendered more or less certain by their
presence or absence.

There may be both pain and palpitation ; yet endocarditis
cannot be surely inferred to exist, unless there be the endocar-
dial murmur withal.* There may be neither pain nor
palpitation, yet endocarditis cannot be inferred not to exist, if
the endocardial murmur alone be present.

Seeing, then, that the endocardial murmur alone can deter-
mine the existence of endocarditis, you are required to search
after it in every case of acute rheumatism. I say emphatically
to search after it, because it is one of those signs which must
always be sought before it can be found. It does not intrude
itself upon our notice like palpitation, or an irregular pulse.
The patient does not draw our attention to it as he does to pain.
The physician must make it out entirely for himself. And
indeed it is infinitely important that he shoidd have the earliest
possible notice of it with a view to the earliest possible applica-
tion of the remedy.

Never omit, therefore, to listen to the pra^cordial region when-
ever you visit a case of acute rheumatism, and visit a case of
acute rheumatism oftener perhaps than you otherwise would do
merely for the sake of so listening. All may seem to be going
on well. The general symptoms may be far from severe. The
chest may be free from pain. The heart's action may not
awaken suspicion by its force or irregularity. Nevertheless,
its internal lining may be inflamed, and, if you listen, the
endocardial murmur may convey the momentous fact directly to
your ear.

* I do not say that it would not be fairly suspected, and that it would,
not Le right to act as decidedly upon the suspicion in such a case as upon
the matter of fact. It certainly would.

64 CLINICAL MEDICINE. [lECT. VI.

LECTURE YI.

ENDOCARDITIS CONTINUED. — ITS GENERAL DESCRIPTION LESS
USEFUL THAN A CLINICAL COMMENTARY UPON ITS INDIVIDUAL

SYMPT0:MS. THE ENDOCARDIAL MURMUR, IN ENDOCARDITIS, IS

SOMETi:\IES PRECEDED BY A CERTAIN ROUGHNESS OR PROLONGA-
TION OF THE heart's NATURAL SOUNDS. OFTEN IT ARISES

ABRUPTLY. SEAT AND DIRECTIONS OF THE MURMUR. ITS

ACCOMPANIMENTS, PAIN, ABNORMAL IMPULSES, AND ACTIONS

OF THE HEART. THEIR PRACTICAL VALUE, AS SYMPTOMS,

ACCORDING TO THEIR DEGREE, AND ACCORDING TO THE DIF-
FERENT RELATION WHICH THE ENDOCARDIAL MURMUR BEARS-
TO THEM IN DIFFERENT CASES. THEIR DIVERSITIES OF RELA-
TION CONTAIN INTIMATIONS RESPECTING THE STAGES AND

PROGRESS OF THE DISEASE. THE SAME CONFIRMED BY THE

SUCCESS AND FAILURE OF REMEDIES. THEIR PRACTICAL

IMPORTANCE.

Endocarditis is one of tliose diseases wliicli do not admit of
general description. For what is meant by the general descrip-
tion of any disease ? It is the display of its symptoms collec-
tively, sometimes by strictly copying after nature, and some-
times using so much of artificial arrangement, as, while it goes
neither beyond nor contrary to nature, may serve to make the
Yv'hole more intelligible. Some such descriptions, when they
have conveyed the truth with great force and faithfulness, have
been regarded with the same sort of pleasure with which we
look upon a well- drawn picture. But, after all, they are more
pleasing than profitable. Perfection in this kind was reached
ages ago, yet we go on describing what has been better
described before, and are venturing with rash hands still to
retouch the masterpieces of Areta3us.

But of those diseases, which have been the most perfectly
described, we have not the most perfect knowledge. The

LKCT. VI.] ENDOCAKDITIS. 65

physician's knowledf^e can then only be called pej'fect, wlien
outward signs make him sure of what is going on within, and
offer some plain and indubitable mark for the direction of his
remedy. This knowledge, however, does not come from dwelling
with satisfaction upon graphic pictures of diseases, nor from
socking to take in all their symptoms, and viewing them at
large, but from meditating on the meaning that is wa-apt up in
a few.

What remains for me to say of endocarditis will be in the
way rather of clinical commentary than description. I shall
take its auscultatory symptom, and a few symptoms beside, and
comment upon them, almost one by one, and show what is the
value that belongs to each in teaching us the realities of the
disease and the use of remedies.

Whenever, then, those conditions of disease arise which are
apt to involve the heart, i.e. in all cases of acute rheumatism
especially, listen to its sounds, and note in them the least
change from what is natural. There may be yet no endocardial
murmur. But its systolic sound may be unnaturally prolonged,
or it may be unnaturally rough. Now I hardly ever knew an
instance of acute rheumatism in which such unnatural length or
roughness of sound, as a practised ear could well discriminate
and detect, has not become an unequivocal endocardial murmur
in twenty-four hours.

Those who have been accustomed to attend me in my visits
to the wards of the hospital, know how often and how truly
from these peculiarities in the sounds of the heart, which I have
noticed for the first time to-day, I have anticij)ated that the
murmur would be fully formed to-morrow. Experience indeed
has taught me to regard them as its almost certain preludes;
and thus, under the circumstances, they have become to me
almost as certain signs of endocarditis as the endocardial
murmur itself. I no sooner jaerceive them than, without
waiting for the murmur, I begin the treatment of endocarditis
at once.

It happens commonly, however, that the natural sound of
the heart is changed into the genuine endocardial murmur,
without notice or prelude. Now the murmur may be heard at
the apex chiefly, or at the basis chiefly, or in both situations
equally. It may, moreover, be heard in the course of the aorta

5

66 CLINICAL MEDICINE. [lECT. VI.

and of the carotid arteries ; or in the course of the pulmonary
artery, and not in the aorta, or in both simultaneously ; thus
denoting that the seat of the inflammation may be either in the
auriculo-ventricular valves or in the semilunar valves ; either on
the left side of the heart or on the right, or on both sides at the
same time.

It has been already said that the murmur being coincident
with inflammatory actions in the constitution at large, deter-
mines the disease of the endocardium to be inflammation, and
that standing alone, and being the only sign directly referable
to the heart, it determines the fact as surely as it would in com-
pany with a dozen other signs immediately pointing to the same
organ. And in truth it sometimes does stand alone, and to it
alone you must needs trust ; and you may trust implicitly.

Often, however, it does not stand alone. Other symptoms
directly referrible to the organ are superadded; pain and
anguish of various degrees and kinds, excessive impulse, inter-
mittent, irregular, faltering, fluttering action of the heart.

Now are these symptoms to be altogether rejected and passed
by ? Have they nothing whatever to teach in this matter, after
the endocardial murmur has already taught what the disease
essentially is? On the contrary, they have a great deal to
teach, and therefore they are to be highly prized and made
much of. In every disease seek to come at the purely diagnostic
symptoms if you can, and put a high value upon them. But
do not imagine that other symptoms have no value at all. You
learn the disease in its essence and seat from its diagnostic
symptoms. But other symptoms commonly tell you of its mag-
nitude, and of its probable event ; other symptoms sometimes
become the guide of its treatment.

The endocardial murmur fixes the seat of the disease without
a doubt, and conditionally determines its nature. But we gain
a surer measure of its degree, and of the peril involved in it,
from the pain and anguish referred to the heart, and from its
disturbed and embarrassed actions.

When pain is present, the time of its first occurrence varies
much in difierent cases. In acute rheumatism I have known
patients, when questioned, admit that they sufiered pain, or
make voluntary complaint of it unasked (pain produced or
augmented by inspiration, pain produced or augmented by

LECT. VI.] ENDOCARDITIS. 67

pressure), in the praccordial region, while yet the ear has detected
no sound of the heart which determined the seat or nature of
the disease. And such pain I have known to cease altogether,
without being followed by the auscultatory signs of either of
those diseases of the heart which so frequently accompany acute
rheumatism, endocarditis, or pericarditis. But from such pain
experience would lead me to anticipate that the auscultatory
signs of one or the other would quickly follow ; and prudence
would lead me at once to begin the treatment of the anticipated
disease.

I have mentioned a certain length and roughness of sound
to which my ear is accustomed, as a frequent prelude to the
endocardial murmur of endocarditis. Praecordial pain may be
added to this length and roughness of sound ; and, when it is,
the murmur is so sure to follow, that it would be folly to delay
the treatment of the disease until it arrives.

PraBcordial pain occurring thus early, and after the manner
specified, may serve at least as a salutary warning of what we
are to expect and to be prepared for. And salutary, indeed (I
am persuaded), it has sometimes been, when it has led us to act
upon a strong anticipation of the disease instead of waiting for
the authentic sign of its actual existence. For thus, if we
have begun the treatment only a single day sooner than we
otherwise should have done, we may have perfectly cured the
disease which, but for the gain of this single day, would never
have been more than half cured. The gain of a single day in
the treatment of endocarditis is a gain indeed !

But the praecordial pain may not arise until the endocardial
murmur has already informed us what disease we have to deal
with, and we have already taken our measures for its cure.
From the prajcordial pain thus occurring, I do not see what
new suggestions of treatment can be gained. But many new
suggestions may be gained from it (as I have already intimated),
according to its degree and its kind, respecting the disease
itself and the peril which it involves.

In endocarditis some patients say nothing of any pain they
suffer until they are asked about it, and others complain of it
unasked ; while there is nothing in the countenances of either
that tells you that they are suffering pain. Pain of this
amount need not disturb your calculation of the result.

68 CLINICAL MEDICINE. [lECT. VI.

Others at once betray their pain by the countenance ; and
being questioned about it, will speak of an indescribable
anguish, which they refer to the praecordial region. This is its
centre, and hence it radiates ; but it has taken possession of the
whole nervous system. Now pain or anguish of this kind (call
it what you will) deserves to be taken into serious account. It
denotes that the disease has already got the springs of life
within its grasp, and that going on to increase it must kill.

Just as the pain, when it is superadded to the murmur in
endocarditis, gives intimations of a more or less formidable
disease, so do the actions of the heart in like manner, according
to the degree in which they are baffled or disturbed.

Some excess of the heart's impulse is a very common
symptom of endocarditis. It often precedes the murmur in
point of time, and often it rises simultaneously with it, and no
sooner do you hear the one than you feel the other. It is apt
to occur very early.

Not so common as excess of impulse, but still not an unfre-
quent symptom of endocarditis ; not always so very early, but
still not a late symptom of endocarditis, is an intermittent
action of the heart. I think where the intermittent action
occurs, it will be found generally, perhaps always, to follow an
excess of impulse ; and then both will exist together in the
same case.

But neither from mere excess of impulse, nor from the
intermittent action of the heart, if the intermissions be not
frequent, need any great apprehension arise. With the
advantage of early treatment, the intermittent action commonly
soon subsides, and the excess of impulse not so soon, but not
long afterwards, leaving the murmur alone. Upon these
symptoms, however, while they remain, attention must be
always steadily fixed. For, if the case have not the benefit of
early and efficient treatment, or be in its own nature intractable,
they are changed into disordered actions of another kind, and
of formidable import : the excess of impulse passing into
extreme feebleness of contraction ; and the rare intermissions
into small, unequal, irregular flutterings.

By the time the movements of the heart are brought to
this condition, that dreadful pra3cordial anguish, which has been
described, has already appeared ; and presently the whole

LECT. VI.] ENDOCAEDITIS. 69

vascular system, and the whole nervous system, and every
organ and every function which supports life, are baffled and
overwhelmed. Then come orthopna-a, and lividity, . and
threatened suffocation, and impossibility of sleep, and collapsed
features, and jactitation, and delirium, and death.

In this manner may endocarditis, announced and specially
characterised by the endocardial murmur, and marked in its
progress by one bad symptom after another, run on rapidly to
a fatal termination. But hitherto, with all the experience of
the disease which this hospital has afforded me during sixteen
years and more, I have never witnessed it end thus.

But I believe such an event may and does happen, upon the
credit of those who have witnessed it. And I believe it the
more, from having myself occasionally seen a state of things
which manifestly tended towards it, but which never reached
it, yet which served to show me how possible it woidd be for
endocarditis to be fatal in its acute stage.

Therefore, in every case, as soon as the murmur announces
that the endocardium is inflamed, I consider that I have surely
a serious, and ipossibly a fatal, disease to deal with ; and I
employ without delay the remedies upon which experience has
taught me to rely for arresting its progress.

Nay, more, so important do I consider the gain of time in
the treatment of endocarditis, that (as I have already said) I
deem myself justified in acting upon a strong expectancy of
the disease, before the murmur has yet unequivocally de-
clared it.

The diversities of relation which the endocardial murmur is
found to bear to other symptoms belonging to the heart in
various cases, are well worth a little farther notice and con-
sideration. For from remarking these diversities, and calcu-
lating together with them the success or failure of remedies,
according to the time and conditions of their application, I am
led to conclude that the endocardial murmur also bears, in
different cases, a different relation to the actual stages and
progress of the disease itself — a fact which, if it be true, must
have important practical bearings.

I believe then, 1st, that in some cases of endocarditis the
murmur is coincident in point of time with the very commence-
ment of the inflammation ; 2ndly, that in some, and those the

70 CLINICAL MEDICINE. [lECT. VI.

most frequent, cases it does not arise until the inflammation has
somewhat advanced; 3rdly, that in some, and those the least
frequent cases, it does not arise until the inflammation is on the
decline, or has actually ceased.

1st. The coincidence of the murmur with the commence-
ment of the inflammation seems tlius denoted. Upon a review
of cases, I find that it was often the first symptom detected.
The patients had hitherto suffered no pain or uneasiness of the
pra;cordial region, no palpitation, no dyspnoea. But the
murmur being once heard, pain, palpitation, and dyspnoea, one
or all of them, quickly followed.

Here then, if ever, the murmur marks the beginning of
the disease; since, if the disease existed prior to the murmur,
it must have existed for a time without any symptom at all.
The fact is rendered more probable from these further con-
siderations. It was in these cases that medical treatment,
promptly applied, was often successful; and it was in these
cases, more frequently than in any other, that the murmur
altogether ceased under the use of remedies, and so afibrded
the best evidence we can have of a perfect cure.

2ndly. The postponement of the murmur to a somewhat
more advanced stage of the inflammation seems denoted thus.
Upon a review of cases, I find that in the majority of them the
murmur was preceded by other symptoms more or less referable
to the heart — such as pain or anguish, palpitation or dyspnoea;
and that an interval of from one day to a week was apt to
elapse between the first appearance of such symptoms and the
subsequent accession of the murmur.

Now, although the symptoms enumerated could only direct
suspicion to the heart, and had they passed away without any
accession of the murmur, it must have remained doubtful in
what manner the heart had been afiected, or whether it had
been afiected at all, yet the murmur, when it at length arrived,
became the sure interpreter of all that preceded it. It declared
the other symptoms to proceed from the same disease as itself,
— viz. endocarditis; and that this disease had existed as long
as they had existed, and for some time before it became
audible.

The efiects of remedies in these cases, both by their success
and their failure, pointed distinctly to the same conclusion.

LECT. Vr.] ENDOCARDITIS. ' 71

There were among- tlieni examples of perfect cure; these were
the cases in which the murmur was preluded for a day or
two by prcecordial pain, palpitation, and dyspnoea comincj on
ichile the imticnU were already under medical observation. These,
as soon as they appeared, served as signals to direct the
remedies to the heart. Thus the treatment of the endocarditis
was instituted in anticipation of the disease, before its authentic
sign had yet arisen and determined its undoubted character
I say, in anticipation of the disease — I ought rather to say in
anticipation of our own certain knowledge of it; for the
murmur after the lapse of a few days arose, and thus distinctly
marked the nature and seat of the disease. But in a few days
it ceased, and thus distinctly marked the perfection of the cure.

Again, among the cases belonging to this class there were
many of imperfect cure. These were those in which the
murmur was preluded for a longer time by proecordial pain,
pal^jitation, and dyspnoea, which came on he/ore the patients iccre
yet under medical observation. It was not uncommon to find in
the subjects of acute rheumatism that proccordial pains and
jialpitations had existed for two or three days before their
admission into the hospital, and yet there was no murmur ; and
that these pra:cordial pains and palpitation would still continue
for two or three days after their admission, ere any audible
roughness or murmur was detected. Here the treatment was
instituted at the earliest period possible under the circum-
stances, and was still beforehand with our knoiclcdge of the
disease; but it v/as too late for the disease itself. At length the
murmur arose, showing Avhat all the previous sjanptoms meant,
and declaring the disease, both what it was and where it was,
and sanctioning its conjectural treatment. But having arisen,
it never ceased, and thus distinctly marked the imperfection of
the cure.

These facts hardly leave it doubtful, that endocarditis and
.all its essential morbid processes, as well as the opportunity of
its treatment, are often comprised within a period prior to any
audible murmur ; that even within this period the disease
begins and advances, and often proceeds so far as to do an
irreparable injury to the endocardium; and that within this
period the opportunity of its treatment must be promptly seized
to be successful, and that, if tardily used it, will even then fail.

72 CLINICAL MEDICINE. [lECT. VI.

3dly. That sometimes the murmur does not arise until the
inflammation is on the decline, or has actually ceased, seems
very probable from the folloAving considerations. There were ii
few well-watched cases in which this happened. During the
progress of the rheumatic fever and the patient's confinement to
bod, no murmur was audible ; but when the fever and the rheu-
matism had ceased, and the patient had loft his bed and was
walking about the ward, and was already deemed convalescent,
then the murmur was for the first time audible. In these cases,
any previous symptoms whicli could intimate a possible suspicion
of the heart being affected were very slight, and had yielded to
slight remedies, or no such symptoms were either noticed or
treated at all.

The endocardial murmur arising under these circumstances
was unchanged by medical treatment. It remained as long as
the patients continued under observation.

The inference from such an event is clearly this, — that an
inflammation of the endocardium had accomi3anied the rheumatic
fever ; that this inflammation was of small activity, and insufla-
cient during its progress to interfere with the natural sensations
and movements and sounds of the heart, but enough in the end
to produce by its effects some permanent inequality on the
surface of a valve, and a permanent murmur as the sign of it.

Now, if the foregoing facts be true, and the conclusions
from them be just, they will help us greatly in estimating the
real value of the murmiir as a sign diagnostic of inflammation
of the endocardium, and as a guide for its treatment.

And its value must vary exceedingly in both respects, ac-
cording to the period of the inflammation at which it becomes
audible. When the murmur is itself the first s}Tnj)tom, or
among the first symptoms, of endocarditis, then it has its highest
jDossible value both for diagnosis and treatment. It makes us
sure of the disease as soon as it begins to exist, it makes us bestir
ourselves for its cure when it is most within reach of a remedy.

But when the murmur is not audible until the endocarditis
is considerably advanced, and until it has already been preceded
for some days by other symptoms, doubtless it is still diagnostic
of the disease, and is still a guide to its treatment ; but its
practical value in the individual case is diminished. For now,,
did we wait for the murmur to tell us what the disease is and

L^CT. VI.] ENDOCARDITIS. 73

Low to treat it, it would inform us indeed at last witli more
certainty than any other sign ; but we should come in with our
knowledge and with our remedies when they were too late.
But we do not wait. Our experience of the frequency with
which the murmur follows such and such .symptoms referable to
the heart, arising in the course of acute rheumatism, makes us
regard them as its sure precursors, and makes us act as if it
were already present, and begin the treatment of endocarditis
while it is yet not quite certain whether the disease be endocar-
ditis or no. Here the value of the murmur is indeed very
great, in a certain point of view. Its value is not shown by
the use we make of it for the diagnosis and the treatment of the
very case in which it occurs, but by the use we make of our
foregone experience of it in other cases, which we are now turn-
ing to such eminent profit in this. The murmur, when it at
length arises in the individual case, only serves to show, that
the conjecture which we formed from the more equivocal
symptoms, concerning the existence of endocarditis, was right,
and that the treatment instituted upon that conjecture was
right also.

Further, when the murmur is not audible until the endocar-
ditis is on the decline or has actually ceased, it is of no use
whatever, either for the diagnosis or treatment of the disease as
an inflammation. The inflammation is gone by, and the murmur
denoted nothing about it during its j)rogress. But it is diag-
nostic of its efiects, which remain and are permanent. What-
ever use and interest it now may have, they belong to it as
marldng the commencement of a series of pathological changes
which are yet to come. For it ascertains beyond a doubt the
time, and the nature, and the seat of the first rudiment of dis-
organisation, which will in the end probably involve the whole
heart.

CLINICAL MEDICINE. [lECT. VII.

LECTUEE VII.

PERICARDITIS. — THE EXOCARDIAL MURMUR ITS PRE-EMINENT
SIGN. — AN IMPERFECT MURMUR SOMETIMES PRECEDES THE
TRUE. IN PERICARDITIS, AS IN PLEURISY, ANOTHER AUSCUL-
TATORY SIGN BESIDE THE MUR:MUR, DULNESS TO PERCUSSION.

THEIR RELATION TO EACH OTHER NOT EXACTLY THE SAME

IN THE TWO DISEASES. IN PERICARDITIS OTHER SIGNS

IMMEDIATELY REFERABLE TO THE HEART, BESIDES THE
AUSCULTATORY : VIBRATIONS SENSIBLE TO THE TOUCH, UNDU-
LATIONS TO THE EYE. OTHER SYMPTOMS OF PERICARDITIS.

THEIR RELATION TO ITS AUSCULTATORY SIGNS. FROM THESE

OTHER SYMPTOMS, AND CHIEFLY FROM ITS KNOWN CONNECTION
WITH ACUTE RHET:MATISM, PERICARDITIS OFTEN RIGHTLY
PRESUMED TO EXIST, AND OFTEN SUCCESSFULLY TREATED ;
YET OFTEN OVERLOOKED, AND OFTEN TREATED TOO LATE,
AND OFTEN FATAL, FOR WANT OF THE AUSCULTATORY SIGNS.

Before the exocardial murmur was made out and verified, and
clearly discriminated from aU other signs referable to the heart,
there was no certain diagnosis of inflammation of the jDericar-
dium. The subject is one in which I had myself taken a
peculiar interest, and had done my best to gain accurate in-
formation. But I am now fully aware, that, for a series of
vears, half the cases at least which I regarded as inflammation
of the pericardium were in fact inflammation of the internal
lining.

Surely a lasting debt of gratitude is due from mankind to
those who shall discover an unerring sign of any disease. The
more so, if the disease be of a formidable nature. The more so
still, if the sign declare the disease early enough to bring our
knowledge of its existence fairly within the period that will
allow it to be successfully treated by medicine. All this may
be confidently predicated of the sign in question and of the
disease it indicates — of the exocardial murmur and inflammation

LECT. VII.] PERICARDITIS. 75

of the pericardium : and our debt of gratitude is due to Dr.
AV^atson and to Dr. Stokes of Dublin ; for these two eminenc
physicians pursued their enquiries independently and success-
fully to the same result. Among the great variety of ausculta-
tory signs referable to the heart in its different states of disease,
they discriminated the attrition- sounds and set them apart from
all the rest, until finally, by experiment, they referred them to
their proper source, and fixed the conditions of their production
in the pericardium.

But there are other sounds which, prior to experience, would
hardly have been suspected to proceed from the pericardium,
but which, nevertheless really do so. These sounds cannot, like
the ordinary exocardial murmur, be imitated by any simple
device that I am acquainted with. They are said to be like the
crumpling of parchment, the creaking of shoe-leather, the churn-
ing of milk. And I must leave them to be represented by these
similitudes without attempting to describe them ; for I am quite
sure that by no description I could give, and by no similitude to
which I could refer you, would you be at all the better able to
recognise the sounds when you should first hear them. You
must wait till you hear them yourselves ; and then you will
most likely be puzzled until you are told what they are.

Any one remembering what has already been said of its
similitude to the sound produced by rubbing the hands together,
or the cuffs of your coat, or two pieces of strong paper ; also oi
its sensible nearness to the ear when it is applied to the prae-
cordial region ; also of its conveyance to a distance over the
chest, and its non-conveyance in the course of the aorta and
carotids ; any one from this description would at once recognise
the true exocardial murmur on first hearing it, and pronounce
that the disease was pericarditis.

But (what for want of better names I must call) the crump-
ling, creaking, churning sounds require to be more frequently
heard, before they are familiarly known and recognised. Yet
an acquaintance with them is most important and most necessary.
For they as surely indicate the presence of pericarditis as do the
more perfect ordinary exocardial murmurs.

One foi'tunate circumstance, however, belongs to these in-
definite and less perfect sounds, which greatly diminishes the
chance of evil that might be supposed to arise from a doubtful

76 CLINICAL MEDICINE. [lECT. VII.

or postponed decision respecting their exact import as diagnostic
signs. It is this : — wherever any one of them arises in con-
sequence of pericarditis, it becomes changed, in the course of
one or two days, completely or partially, into the genuine exo-
cardial murmur. It is either merged entirely in it, or partakes
enough of its character to leave its import no longer doubtful.
And then the genuine murmur being once established continues
such thenceforward through the whole course of the disease, or
only changes its character a few days before its final disap-
pearance.

Touching these indefinite sounds referable to the heart in
acute rheumatism, there is another circumstance which is worth
a particular notice. It is this— that they will sometimes come
and go for two or three days, and then cease altogether, or then
become permanent.

For an important fact, not prominent in itself, it is often
difficult to gain the attention it deserves, unless you invest it
with the circumstances of actual practice. Let me do so for the
fact in question. This then has several times happened. A
clinical clerk, having charge of a case of acute rheumatism, has
distinctly heard an umiatural sound at a certain space of the
priccordial region, and two or three other students have heard
the same as distinctly as himself. The space has been a small
space, and they have marked it with a circle of ink that they
might the more easily find it again. At my visit to the hospital
some time afterwards my attention has been called to the fact ;
but no such sound could I hear, and those who have heard it
before have confessed that they could not hear it now. But I
have returned to the same patient in half an hour, and then I
have heard it, and everybody else has heard it distinctly and at
the very spot indicated.

Now, these sounds of an indefinite kind, belonging to acute
rheumatism, which are restricted to a small praecordial space,
and are now audible and now inaudible several times a day for
two or three days together, and then either become constant or
entirely cease, always proceed (I believe) from the pericardium.
For, when they become constant, they gain the character of the-
ordinary exocardial munmir, and spread themselves widely over
the prascordial region or beyond it.

In the cases where the sounds idtimately cease without

LECT. VII.] PERICARDITIS. 77

becoming cither more pronounced or constant, and without
occupying a larger space, it is reasonable to believe the disease
still to have been pericarditis, but of small degree and extent.*
In connection with the more or less perfect exocardial
murmur, many circumstances remain to be noticed which are of
great interest, and which serve further to illustrate the patho-
logy and diagnosis of inflammation of the pericardium.

You recollect the history formerly given of the attrition-
goimd occurring in the course of pleurisy ;t how it arose at one
period of the disease, ceased at another, and returned again at a
third. The solid products of inflammation, the lymph, upon
the opposite surfaces of the pleura, first produced the soimd.
The fluid products of inflammation, the serum, in the cavity of
the pleura, obliterated it. And the absorption of the serum
from the cavity, while the lymph still remained upon the sur-
faces, caused it to return.

Now in pericarditis there are the fluid products of inflam-
mation as well as the solid. There is serum as well as lymph.
And the signs of fluid efi'used within the pleura and the pericar-
dium are the same. The fact of its existence, and the measure
of its accumulation within the pericardium, can only be known
by the degree and extent to which the proecordial region, and
perhaps some space beyond it, may be dull to percussion. Thus
in pericarditis dulness sometimes occupies a jjart and sometimes
the whole of the praecordial region ; sometimes it reaches beyond
the praecordial region, as high as the second, and even the first
left rib ; sometimes it extends beneath the whole length of the
sternum, except about an inch at the top, and even beneath the
cartilages of the ribs on the right side.

* I would not willingly represent the diagnosi:^ of the seat of disea^je
within the heart by the quality of its abnormal sounds, as more easy, or
more constant, or more absolutely sure than it really is. Notice is here-
after (page 86) taken of certain cases, in which it could not be determined
whether the inflammation was of the endocardium or of the pericardium.
Dr. Bence Jones informs me, that at St. George's Hospital he has sometimes
found no distinction possible between the endocardial and exocardial
murmurs themselves ; and that then the variations of sound, from day to
day, and even from minute to minute, and often in consequence of cliange
of position, have aflbrded him the means of recognising inflammation of the
pericardium.

t In the course of lectures given at St. Bartholomew's, those on pleurisy
preceded those on diseases of the heart.

78 CLINICAL MEDICINE. [lECT. VII.

Surely, then, this dulness to percussion is a most important
sign, and hardly inferior to, and hardly less diagnostic of, the
pathological conditions to which it points, than the exocardial
murmur itself.

But do these two, viz. the murmur and the dulness, bear
the same relation to each other as signs of disease within the
pericardium, as they have been seen to bear as signs of disease
within the pleura ? In pleurisy the attrition- sound and the
dulness are never coincident, but are always found to supersede
each other, one ceasing as soon as the other arises. Is this the
case in pericarditis ? My own experience would answer almost
absolutely " No ! " As soon as I have discovered the exocardial
murmur at any part of the praecordial region, so soon have I
almost always found dulness to percussion. And, to whatever
extent the dulness to percussion has spread beyond the praecor-
dial region, the murmur has accompanied it, even as high as the
first left rib, and beneath the sternum, and far beyond it, even
to the juncture of the cartilages with the right ribs. Further,
I have known dulness of the praecordial region to be the first
sign, and to subsist several days alone, and yet the attrition-
sound has at length been superadded to it, when they have
thenceforth been continued together. In pericarditis, then,
this I take to be the general truth, namely, that the murmur,
which is produced by lymph, deposited upon the surfaces of
the membrane, is neither abated, nor abolished, nor otherwise
altered in its character by the serum effused within its cavity.
It is not, however, the universal truth.

Indeed, I have seen a few instances of pericarditis, where
the murmiir, clearly heard day after day, has at once become
very indistinct, or has been suddenly lost altogether. The
disease has been at its greatest activity, and the heart at the
very time has suffered some extraordinary bafflement of its
actions. But the sound, thus abated or abolished, has suddenly
returned, and in a day or two has been as perfect an exocardial
murmur as it was before, and then the heart's actions have
recovered their regularity. In these instances the remedy
which has thus instantly relieved the heart and restored the
sound has been a large blister vesicating the whole praecordial
region, and a wide space around it.

Now dwell a little thoughtfully upon these instances, and

LECT. VII.] rERICARDITIS. 79

upon tlio several attendant circumstances, both when the sound
goes and when it returns, and above all, upon the remedy, and
its immediate effect ; and then say what they can denote, but
now a sudden increase, and now a sudden decrease, of fluid
within the pericardium ?

But still, if the common experience be In accordance with ray
own, and if my own speak the truth in this matter, the fact will
be, that serous effusion within the pleura alivays obliterates the
attrition- sound, and that serous effusion within the pericardium
generallj/ leaves it unaltered. Now there must be some way of
accounting for so different a result from conditions apparently
the same. The following considerations, perhaps, point out a
way that is plausible at least.

Fluid within the pleura exercises Its pressure upon the most
yielding organ of the body, the lungs. They make no resistance,
but, shrinking in their dimensions, and giving place more and
more as the fluid increases, they recede further and further
from the ribs, until at length they are forced into an incredibly
small compass by the side of the vertebral column, impervious
to air and useless, but in themselves perfectly free from disease.

But fluid within the pericardium produces no such effect
upon the heart by its pressure. The heart, of all organs of the
body, is the least yielding. It is the pericardium that now
3'ields. But then, in the greatest accumulation of fluid within
it, the space intervening between the pericardium and the heart
will bear no comparison with that between the pleura and the
lungs in ordinary cases of pleurisy. Further, when in peri-
carditis death has taken place while the inflammation was
progressive, dissection has generally found as much solid as
fluid matter within the pericardium, and sometimes even more
lymph than servmi. The heaped-up, curdled albumen covering
the entire heart, and adherent to, or pendulous from, the loose
pericardium, would make it appear that the interposed serum
(which itself contains flakes of lymph) was not enough to pre-
vent the opposite surfaces from touching and rubbing against
each other, and so to prohibit the murmur.

In the few cases where the dulness to percussion supersedes
the murmur, or greatly alters its character, it is probable that
the fluid products of inflammation exceed the solid, that the
serum exceeds the lymph, in an unusual measure.

80 CLINICAL MEDICINE. [lECT. VII.

The exocardial murmurs of more and less perfect character,
and the dulness to percussion of the praecordial region, and of
more or less space beyond it, are strictly auscultatory^ signs,
being both equally learnt and appreciated by the ear. It is
with such that I am now principally concerned. But I may be
permitted perhaps to conjoin with them two other signs, directly
referable to the heart, indicating the same conditions of disease
and often found in their company, but learnt and appreciated
by an appeal to other senses.

In pericarditis, while the praecordial region is dull to per-
cussion and the exocardial murmur is heard, an undulating
motion often becomes visible to the eye in some of the spaces
between the cartilages of the ribs on the left side. It has always
been either between the cartilages of the second and third ribs,
or of the third and fourth, or between both at the same time,
that I have seen this motion, and never in any other situation.
So, too, in pericarditis, while the praecordial region is dull
to percussion and the murmur is heard, a vibratory motion often
becomes sensible to the touch in some of the spaces between the
cartilages of the ribs on the left side. As I never saiv the
undulatory, so I never felt the vibratory, motion elsewhere
than either between the cartilages of the second and third , or of
the third and fourth ribs, or between the cartilages of both
simultaneousl}'.

The vibration (I believe) is the more frequent of the two,
and often occurs unaccompanied by any visible undulation.
But the undulation was never apparent to my eye without my
finger being able to detect a sensible vibration at the very same
spot.

It is hardly necessary to give a formal explanation of these
phenomena. It is no unusual thing that the same vibrations
which convey sounds to the ear should make themselves sensibly
felt by the touch, or that a fluid should impart its own undu-
latory motion to contiguous bodies.

Now these two signs, which address themselves respectively
to the sight and to the touch, are simple, direct, and easily
apprehended, but inferior in value, both to the murmur and to
the dulness on percussion, as pointing out inflammation of the
pericardium. Neither the vibration to the touch nor the un-
dulation to the eye are always present. Many a case of

LECT. VII.] rERICAKDITIS. ) 81

pericarditis has passed through its entire course without cither
one or the other manifestinn; itself. So that, if avo depeudcd
altogether for our diagnosis upon either or both, pericarditis
must often go undiscovered.

Again, where they do appear, it is not (as far as I observe)
ever at a very early period of the disease. So that, though
they might afford a sure diagnosis enough, it would be less
practically valuable as coming late, when the time for the most
efficient treatment of the disease is past.

But fortunately our diagnosis of pericarditis need never
depend upon them ; and more fortunately still, our diagnosis is
already settled before they appear. For in pericarditis (as far
as I have observed) they never occur but as accompaniments of
the exocardial murmur and the praccordial dulness. And farther,
when they do occur (as far, as I have observed), they always
appear later, and cease earlier, than these do.

There remains another observation to be made in calculating
the just value that belongs to one of the two signs in question,
viz. the vibration conveyed to the touch between certain inter-
costal spaces. It is occasionally present in more diseases of the
heart than one ; in disease of the semilunar valves, whether of
the pulmonary artery or of the aorta, as well as in inflammation
of the pericardium. Which disease it indicates, and in which
situation, must be determined by the concurrent circumstances
of the particular case.

It would not then perhaps be unjust to conclude that the
exocardial murmur and the prcecordial dulness are supreme in
the diagnosis of pericarditis ; and that they neither receive
nor require any aid fi'om other signs directly referable to the
heart, though such (it appears) there are, which are as simple,
and as plainly cognisable by other senses as themselves are by
the ear.

Thus far I have been dealing with these auscultatory signs
analytically ; setting them apart, and describing what they are
in themselves, explaining the mode of their production, and the
conditions out of which they arise, and comparing them with
others that might seem to hold competition with them. And
perhaps I have thus made them as intelligible to you as in this
manner they can be made. You may now understand their
proper sphere of diagnosis, and their just value ujwn the ivhole.

6

82 CLINICAL MEDICINE. [lECT. VII.

But, for tlie great uses they are to serve, 3'ou must become
acquainted with them in their accustomed complications, and
mixed, as nature mixes them, with the events and circumstances
of actual practice.

My own experience of pericarditis is mainly derived from
what it is, as an accompaniment of acute rheumatism. I have
seen the disease, indeed, under other circumstances. But it
has been very seldom; so seldom, indeed, that I have little
acquaintance with other conditions external or internal con-
ducing to it. I can neither tell whence to look for it nor when
to expect it, except when it occurs as a part of acute rheu-
matism.

The pericarditis, which is acute and rapidly progressive,
and, unless arrested by timely and effectual treatment, full of
peril, this is the pericarditis I mean. And with this the prac-
tice of a large hospital has rendered me familiar by presenting
me every year with numerous instances of it in alliance with
acute rheumatism. But, separate from acute rheumatism, even
the practice of a large hospital does not present me with more
than an instance or two of it in several years. And, as of the
disease itself, so of all the symptoms and auscultatory signs by
which I learn its existence and direct its treatment, my chief
knowledge comes from acute rheumatism.

In analysing the sources of our knowledge, let us be just
in allowing to all times and to all methods of investigation
their due merit. It ill beseems that impartiality which ought
especiall}^ to characterise every enquiry after such truths as we
are engaged in, to be bent upon depreciating the labours of the
past age and exalting those of the present, or disparaging old
methods of research and praising new ones. Pathology and
practical medicine had assuredly made some respectable ad-
vances before we were born, and before physicians had found
out all the uses of their ears, and of the stethoscope.

Long before auscultation was practised, physicians knew a
great deal about inflammation of the pericardium. They knew
well the pathological conditions of the constitution at large out
of which it is most prone to arise, and consequently when to
expect it. They knew well when to infer its existence from
such symptoms as were within their reach. They knew well
how to treat it, using all the same remedies that we do now.

LECT. VII.] PERICARDITIS. 83.

and (lircctin<> them to fulfil the same indications. Finally,-
they knew well all its consequences. Long before auscultation,
pericarditis had a good claim to be considered one of those
diseases which was tolerably well understood.

^ow that which served our predecessors as the basis of all
they knew clinically concerning pericarditis was the general
fact of its alliance with acute I'heumatism. This fact, so sure
and well authenticated, gave an interpretation and a meaning
to many equivocal circumstances, and placed them, for the time,
almost in the rank of diagnostic symptoms.

The direct symptoms from which they inferred its exis-
tence were these ; — pain in the pra^cordial region, often
augmented by pressure, anguish, and oppression of breathing,
and an irreo^ular or intermitting action of the heart. But these
symptoms are not very precise ; they have been found in other
diseases of the heart, and in diseases of other thoracic organs.
It may seem strange, then, that physicians having only these
to guide them should be able to detect pericarditis so often and
so surely as they did. But then (I repeat) they knew the
■conditions imder which pericarditis was apt to occur ; and,
when those conditions arose, they were perpetually upon the
watch for it. And thus when, in the midst of acute rheu-
matism, there arose a praecordial pain, an anguish of respiration,
and an irregular action of the heart, they interpreted them to
denote pericarditis, and they were generally right.

They were right, when these signs occurred in acute rheu-
matism, in concluding them to mean pericarditis ; but, lohen in
acute rheumatism not one of these signs occurred, and the peri-
■carditis existed nevertheless, they overlooked the disease ; and
they could not help but overlook it. And when (what more
frequently happened) these signs occurred indeed, but not
until the pericarditis had already existed many days, they did
not overlook it, but they gained too late a knowledge of it,
much precious time having been already lost to its treatment.
Thus pericarditis has indeed been entirely overlooked by my-
self, and by better men than myself ; overlooked when we were
most upon the watch for it, under circumstances most con-
ducive to it, even as the accompaniment of acute rheumatism.
The inflammation has been severe, and, being unarrested by
any remedy, it has run on rapidly to its fatal termination ; and

84 CLINICAL MEDICINE. [lECT. VII.

after death we have stood amazed at the disease disclosed to
our eyes by dissection.

These are events of past years. In such unfortunate cases
there was neither proecordial pain, nor respiratory anguish, nor
irregukr pulse ; and the auscultatory signs of pericarditis were
as yet unknown. But the like mistakes could hardly occur
note ; it is scarcely possible that jjericarditis coming on just at
the suspected time, and just under the suspected circumstances,
could noiv be overlooked. Every pinxdent physician, I presume,
searches after it day by day with his ear in all cases of
acute rheumatism ; and though the heart itself show no vital
consciousness of its ailment either by feeling or function, by
pain or palpitation, — though the organs in closest relation with
the heart, the lungs, feel nothing, suffer nothing, and declare
nothing, and so there be no dyspna3a, yet will the mere
mechanwn of the disease proclaim the fact of its existence to
the ear.

By reason of its perfect lubricity, the healthy pericardium
carries on the movement of its surfaces upon each other in
perfect silence. It is enough to make their movement audible
if inflammation do but sj)oil this perfect lubricity, and as soon
as inflammation produces ruggedness and inequality, the move-
ment is accompanied by harsh sounds .

Still, of an acute and severe rheumatic pericarditis running
on to its fatal termination, absolutely unattended from first to
last by any symptoms except the auscultatory^, the examples, I
believe, are very rare ; few at any time have died of it without
any atteraj^t to save them. The victims of an undiscovered
and imtreated pericarditis are few ; but the examples (I am
persuaded) are by no means rare of an acute and severe rheu-
matic jDcricarditis progressive for many days, and unattended
in the meantime by any but auscultatory symptoms, other
symptoms, however, arising at last ; and many such cases (I
am persuaded) Avere fatal formerly. The best treatment com-
menced as soon as the only symptoms then understood had
declared themselves, came too late ; and many such cases would
be fatal no^o, did not the first attrition-sound from the pra:-
cordial region call into instant use the remedies by which we
deal with pericarditis.

My experience tells me, that in acute pericarditis the

LECT. VII.] PERICAKDITIS. 85

fluttering, fiiltcring action of the heart, and, with it, the
respiratory anguish, arc almost sure to occur, but that the time
of their occurrence is almost always late, and that the murmur
and the pra)cordial dulness always precede them.

But my experience tells me, that in acute pericarditis tlie
pain, if it occur at all, almost always occurs early. The first
access of inflammation generally produces it as well in the
pericardium as in other parts. Yet, early as is the pain, the
murmur is often earlier.

But of all symptoms mere pain is the most inconstant and
uncertain, whatever be the disease. It is so in pericarditis. It
is present in one case, and absent in another strangely and
unaccountably. I have known much pain, when the disease
has been of little severity, of short duration, and of easy cure :
and I have known the severest pericarditis pass through all its
stages without pain. All other symptoms have been present
to mark its reality and its progress : the murmur and the pra)-
cordial dulness, and the fluttering heart, and the respiratory
anguish. And sometimes the patient has died, and sometimes
he has escaped by a tardy and precarious convalescence. But
from first to last there has absolutely been no pain.

Do not be surprised at this. Pleurisy may exist without
pain ; even acute, rapid, pus- effusing pleurisy. Peritonitis may
exist without pain ; even acute, rapid, pus-eft'using peritonitis.
And so, too, if in pericarditis there is sometimes no j^ain, it
fortunately happens that there are other signs by which we
-can fix our diagnosis of the disease equally well without it.

See what a strange, imequal, and uncertain light pain is
found to throw upon diagnosis and treatment ! We find it
where we do not look forit, and look for it where we do not find
it. Its presence is no sure proof, its absence is no sure nega-
tion, of disease.

But still pain is a most important symptom. Where there
is pain, we should always think of disease, always search after
disease, and always require strong circumstances to convince us
•that disease does not exist. AVhere there is no pain in a part
suspected of disease, we should never on that account conclude
it to be healthy, and never be content until we find other cir-
•xjumstances to convince us that it is really so.

8G CLINICAL MEDICINE. [lECT. VIII.

LECTURE yill.

THE FREQUENCY OF ENDOCARDITIS AND PERICARDITIS, OCCURRING
SEPARATELY OR TOGETHER, AS THE ACCOMPANIMENTS OF
ACUTE RHEUMATISM. — PRESENT RESULTS OF ENDOCARDITIS

OCCURRING ALONE. OF PERICARDITIS OCCURRING ALONE, — OF

BOTH OCCURRING TOGETHER. DIFFICULTY OF GAINING KNOW-
LEDGE OF THEIR ULTIMATE RESULTS, WHEN THE CURE IS
IMPERFECT.

Between the years 1836 and 1840, both, inclusive, there
occured under my care at St. Bartholomew's Hospital 136 cases
of acute rheumatism :

Of these 136 j^atients 75 were males, and 61 were females ;
of the 75 males the heart was affected in 47, and unaffected
in 28.

Of the 47, the seat of disease was the endocardium alone in
30 ; the pericardium alone in 3 ; and both the endocardium and
the pericardium in 7. And, while the heart was undoubtedly
affected in 7 others, the exact seat of its disease was uncertain.

Of the whole number of males in whom the heart was thus
variously affected 3 died. And in these 3 the pericardium and
the endocardium were both inflamed.

Of the 61 females the heart was affected in 43, and unaffected
in 18.

Of the 43, the seat of disease was the endocardium alone in
33 ; the pericardium alone in 4 ; and both the endocardium and
the pericardium in 4 ; and the exact seat of the cardiac disease
was doubtful in 2.

Of the whole number of females in whom the heart was thus
■variously affected none died.

The account of males and females taken together will stand
thus : —

Cases of acute rheumatism .... 136
Heart exempt in . . . . 46

Heart affected in . . . . .90

LECT. VIII.] FREQUENCY OF ENDOCARDITIS, ETC. .S?

Seat of disease in the heart : —

Endocardium alone in . . . .63
Pericardium alone in .... 7

Endocardium and pericardium in . .11

Doubtful in 9

Deaths 3. In all of whom both the endocardium and the
pericardium -svere affected.

Here are momentous facts which go (I suspect) a good deal
beyond the ordinary notions entertained by medical men of this
matter. It is believed that among the sufferers of acute rheu-
matism an individual now and then unluckily has his heart
inflamed. The thing is looked upon as an accident which, if
not very rare, yet is not very common. But it appears, from
the event, not of a dozen or twenty cases merely, but of a
number large enough to furnish the measure of what naturally
belongs to the disease, that as many as two-thirds of those who
have acute rheumatism also suffer inflammation of the heart.*

Further, the pericardium is popularly regarded as the special
and most frequent seat of the inflammation which takes its rise
from acute rheumatism. But it appears from cases sufficiently
numerous, that endocarditis occurs nine times in acute rheuma-
tism, for pericarditis once ; that simple endocarditis constitutes
more than two-thirds of all rheumatic cardiac aflfections, and
simple pericarditis only one-thirteenth ; and that pericarditis is
more frequently found in combination with endocarditis than
alone.

Next we come to the results of these cases. And there are
many results worth inquiring about ; but, when the disease is
inflammation, and the part affected is vital, everybody first thinks
* It has been suggested to me that, in the records of my practice at St.
Bartholomew's, thei-e would probably be found a somewhat greater frequency
of endocarditis and pericarditis, as the concomitants of acute rheumatism
than is usually observed; and that this might be owing to the sedulity of
my clinical clerks, who were ever on the alert to gain admission into my
wards of (what were esteemed) interesting cases, and that thus I might get
more than my share of rheumatisms in which the heart was affected. I
cannot exactly tell how this may be, but I hear all physicians of public
hospitals speaking of the heart being affected in acute rheumatism with a
frequency far beyond the common belief.

The proneness of the heart to inflammation in rheumatic fever may not
be at all times the same. It may belong to (what Sydenham would call)
the epidemic constitution of a certain series of years.

88 . CLINICAL MEDICINE. [lECT. VIII.

of the great result in present death or recovery, and asks what
are the hojaes of life and what the fears of death.

Now, you already know that out of the 90 cases of cardiac
disease occurring in the course of acute rheumatism, cases of
simple endocarditis, and cases of simple pericarditis, and of both
mixed, and of some doubtful, only three deaths are recorded.
Well, then, have all these pains and all this care of diagnosis
been thrown away uj)on a class of diseases which, albeit they
are of a vital organ, prove fatal only in one case out of thirty ?

But besides the great result of present death, or recovery
from the present inflammation, there are other results, practically
and pathologically important in the highest degree, which aus-
cultation and auscultation alone has enabled us to trace and to
aj)preciate.

The results of simple rheumatic endocarditis were these : —

Of the G3 patients who suffered simple endocarditis in the
course of acute rheumatism, 30 were males and 33 were females,
of whom none died. And if the sort of subjects we have to deal
with in a London Hospital be considered, their different habits
and constitutions, which are bad in the majority, and the dis-
advantages of their postponed treatment, so common in the acute
diseases of the poor, it must be confessed that the endocarditis
of acute rheumatism does not involve much immediate peril of
life, when of all the cases of this disease, 63 in number, which
occurred in the course of five years, not a single one was fatal.

But of these 63, whom the endocarditis did not kill, and who
as far as general symptoms could be trusted, might be pronounced
convalescent or well, auscultation still told us that, after the
inflammation had ceased, the membrane recovered its complete
integrity of structure only in 17, and that it remained perma-
nently injured in 46. For of the 30 males, the subjects of rheu-
matic endocarditis, the endocardial murmur ceased entirely only
in 8 ; while it remained, after they were convalescent, and as
long as they continued under observation, in 22. And of the
33 females the endocardial murmur ceased entirely only in 9 ;
while it remained in 24.

Thus, while inflammation arrested and life saved in all the
cases which occurred, even 63 in nvimber, do indeed sufficiently
testify how small is the present peril of life from rheumatic
endocarditis, vet the entire restoration of the endocardium to its

LKCT. VIII.] JiESULT.S OF I'EliKJxVKDITIS. 89

perfect structure in 17 only, and the permanent injury done to
it in 40, denote a most fearful disease in regard to its distant
results. For the probability is as g-reat as four to one, that
inflammation befalling the endocardium will become the rudi-
ment of disorganisation to the entire heart.

The results of simple rheumatic pericarditis were these : —

Of the 7 who suffered simple pericarditis in acute rheu-
matism, 3 were males and 4 were females, of whom none died.
Life was saved in all. Inflammation was arrested in all ; and
all resumed the general conditions of health. Neither, after
inflammation arrested and life saved, did it happen to any one
of these cases of pericarditis, as it did to 46 out of 63 of endo-
carditis ; not in a single case did the exocardial murmur remain
after convalescence to denote a still abiding change of structure
in the pericardium, as the endocardial murmur had remained,
and denoted permanent disorganisation of the endocardium in so
many cases of endocarditis.

But were all these cases of pericarditis perfectly cured ?
After the inflammation ceased, was there no remnant of injury
in any case where there was no exocardial murmur to denote it ?

In pericarditis, when the exocardial murmur entirely ceases,
we have not the same strong grounds for believing that the
pericardium has both lost its inflammation and recovered its
healthy condition, as we have in endocarditis, when the endo-
cardial murmur ceases, that the endocardium is quite sound
again. These two auscultatory signs, referable to the internal
and external membrane of the heart respectively, cannot be
taken equally to imply the same things both when they come
and Avhen they go. When they come, they both equally denote
new matter deposited, the one upon the endocardium and the
other upon the pericardium. But when they go, they do not
both equally denote that the newly deposited matter has been
removed. When the endocardial murmur ceases, it does denote
as much ; when the exocardial murmur ceases, it does not. For
the endocardial murmur could not cease, while the lymph still
remained on the endocardium to produce the obstruction to the
blood which caused it. But the exocardial murmur could cease,
while yet the lymph remained on the pericardium. For its
opposite surfaces might by the same lymph be made to adhere,
and thus the cause of the murmur would be removed.

90 CLINICAL MEDICINE. [lECT. VIII.

Hence, therefore, out of the 63 cases of simple endocarditis,
in which inflammation was arrested and life saved, I feel abso-
lutely certain that the cure was perfect in 17 ; a small pro-
portion, indeed ! while out of the 7 cases of pericarditis, in
which inflammation was equally arrested, and life saved, I
have no assurance whatever that the cure was perfect in a
single one.

But although in these and in all cases of acute pericarditis
there is nothing certain beyond the immediate result of the
treatment in arresting inflammation and saving life, there may
be something 7;ro/^rt5^e as to the condition in which the inflamed
parts are left, and as to the perfection or imperfection of their
cure.

What is probable, then, is this, that, whenever the pericar-
dium is acutely inflamed, and lymph enough is deposited upon
it to produce the exocardial murmur, the cure seldom amounts
to a complete restoration of its natural structure, but that the
whole, or some considerable portions of its opposite surfaces,
permanently adhere. This is probable from the nature of the
disease itself, and of the serous membrane which it implicates.
And it is nauch more probable from what actually occurs in
many cases. For after the exocardial murmur has long ceased,
and the patient is deemed convalescent, signs directly referable
to the heart will often remain or arise, showing that the organ
is not at ease — that it still sustains an injury which bafiles and
restrains the freedom of its natural actions. The signs, taken
alone, are not enough to define the injury, either what it is, or
where it is ; but taken in connection with the previous disease
they are quite enough. They denote that the permanent injury
has the same seat as the previous disease, viz. the pericardium,
and that it consists in that change of structure to which inflamma-
tion of the pericardium naturally tends, viz. adhesion of its folds.

In 4 of the 7 cases of simple pericarditis, I find the follow-
ing records made just before the patients passed from under my
observation, and left the hospital: — 1. " Sounds of the heart
not distinct one from the other." — M. 31, 181.

2. " Sounds of the heart as if muffled."— W. 22, 4.

3. " Increased impulse of the heart for a month after the
exocardial murmur had ceased, and as long as the patient
remained under observation." — "W. 25, 121.

LECT. VIII.] RESULTS OF ENDOCARDITIS, ETC. 91

4. " Praecordial region presents a greater extent of dullness
to percussion than natural." — W. 26. 121.*

The results of rheumatic endocarditis and pericarditis com-
bined in the same subject were these : —

Of the 11 in whom endocarditis and pericarditis were
combined, 7 were males and 4 were females. Out of those,
inflammation was arrested, and life saved in 8; and 3 died.
Of the 8, who were convalescent from this double disease, one
of the structures inflamed, the endocardium, underwent perfect
reparation in 2, for the endocardial murmur entirely ceased;
and imperfect reparation in 6, for the endocardial murmur
continued. As to the other structure inflamed, the pericardium,
although the exocardial murmur ceased in all, it is doubtful
whether its reparation was perfect in any. Probably there
remained a greater or less extent of permanent adhesion.

Thus of these 8 cases of double disease, or of inflammation
involving the two structures of the heart, I am not sanguine
enough to believe that the organ recovered a perfectly healthy
condition in a single instance. For in the 2, where, doubtless,
the endocardium was perfectly restored, the pericardium
probably adhered; and in the 6, where, doubtless the endo-
cardium was permanently injured, the pericardium probably
adhered also.

In the 3 fatal cases, the auscultatory signs denoting inflam-
mation of the endocardium and pericardium were well marked,
and on both membranes dissection disclosed the recent effects
of inflammation, when it is arrested in its mid progress by
death.

I subjoin an account of them which you may take as
specimens of the disease: —

In one case the folds of the pericardium were universally
adherent, but were easily separated. The connecting lymph
was peculiarly vascular over the left ventricle, and being
detached, discovered some spots upon the surface of the heart
which looked like pus. The endocardium bore marks of

* The letters and numerals here and elsewhere denote the volumes and
pages of my own ]\IS. case-hooks. I am aware that they can now afibrd no.
help to the reader, since they do not refer to documents open to his consulta-
tion. Still, at some future time the cases may be recorded, and then the
references will be of use.

92 CLINICAL MEDICINE. [lECT. VIII.

inflammation on botli sides of the heart. On the tricuspid
valve, at a little distance from its free edge, was a spot, one-
third of an inch in diameter, pink in the centre, and surroiinded
with a white elevated border. On the mitral valve were smiall
pearly bodies, about the size of millet seeds, fringing its free
edges. The aortic valve was thickened and of a pinkish
colour, and displayed upon its surface, a little below its free
edges, bodies of the same form and size as those found upon
the mitral valve. The general bulk of the heart and the
capacity of its cavities were natural, and its muscular substance
had the appearance of health.

Here the exocardial murmur ceased twelve days before the
patient's death. But the endocardial murmur continued, until
the symptoms of dissolution arose, and the movements of the
heart were too feeble to make it audible. — M. 25. 29.

In another case the pericardium adhered at no part, but was
every where covered, both on its free and reflected surface,
with curd-like lymph, which was accumulated in the largest
quantity over the auricles, and on the basis. The adventitious
membrane being turned back, discovered red spots beneath of
extravasated blood like petechia). The quantity of fluid in the
pericardium was very small, not exceeding two or three
drachms. It was like whe}'. The endocardium showed the
eflfects of inflammation on both sides of the heart. The
tricusjDid valve had minute pearl-like bodies deposited near its
free edges. The mitral valve had bodies of the same kind in
the same relative situation, and around some of them there was
a slight blush of red. On passing the finger from the ventricle
into the aorta, a palpable obstruction was felt in the situation
of the valve. This was found to arise from a single fibrinous
deposit upon one of the valvular processes. It was of an
irregular form, and one-third of an inch in size at its greatest
diameter. All the three processes were slightly thickened, and
of a pinkish colour, but upon one only was there any morbid
deposit. The general bulk of the heart and the capacity of its
cavities were natural, and its muscular substance was apparently
healthy.

Here the exocardial and endocardial murmurs continued,
until the symptoms of dissolution arose. For four days before

LECT. VIII.] RESULTS OF ENDOCARDITIS, ETC. 93

death, the heart could hardly be heard or felt, and all distinc-
tion of sound was necessarily lost. — M. 25. G9.

In the third case the pericardium was only partially
adherent by round loose bands of lymph, and its surfaces,
where they Avcre free were covered by a continuous layer of
lymph, half an inch thick, and studded with rough, unequal,
villous prominences. The pericardium contained about three
ounces of whey-like fluid. The endocardium bore marks of
inflammation only on one side of the heart. The mitral valve
had a rough fringe of minute deposits near the edges of its free
border, and each process of the aortic valve had a fringe of the
same kind, only thicker. The muscular substance was perfectly
healthy. The whole organ seemed rather large ; but it could
hardly be said that any part of its substance exceeded its
natural bulk, or any one of its cavities their natural capacity.

Here the exocardial and endocardial murmurs continued
until the death of the patient. — M. 31. 140.

In contemplating endocarditis and pericarditis united in the
same subjects, do we find ground for believing that either
naturally tends to produce the other ? In 4 of the 1 1 cases
the endocardial was prior to the exocardial murmur; and in 4
the exocardial was prior to the endocardial. In 1 case they
arose simultaneously after the patient's admission into the
hospital, and in 2 they were found already co-existing at the
time of admission.

Such were the results of rheumatic inflammation of the
heart in the 90 cases which fell under my observation in the
course of five years. They include the events of life and
death during the progress of the inflammation, and the condi-
tions of perfect and inperfect cure in which the endocardium
and pericardium were left after its cessation. Here my
observations stopt. And, indeed, in the 17 cases of endocarditis
terminating in perfect reparation, and the 3 of complex
endocarditis and pericarditis terminating in death, it embraced
the entire disease. But in all the rest there were other results
yet to come which my observation could not reach. These are
such as are yet to emerge sooner or later in the course of future
existence. The injured valves, or the adherent pericardiimi,
or both combined, lay their own conditions upon the continuance

94 CLINICAL MEDICINE. [leCT. VIII.

of a man's life, and sometimes settle beforehand the manner of
Ms death.

Sad, indeed, but most interesting and instructive, would be the
entire history of the lives and deaths of all those in whom I here
witnessed the first attack of disease, which spoiled the perfect
structure of the heart. Such an entire history I shall never
know. I may learn a few particulars of one or two whom I
may chance to meet with, and this is all I expect.

But our knowledge of chronic maladies, which last for
years, is not gained in the same manner as our knowledge of
acute diseases, which last for a few days or a few weeks, viz.
hy watching their progress from beginning to end in the same
individual patients.

Our knowledge of chronic maladies is picked up piecemeal
from numerous cases seen for a while, and only for a while, at
different periods of their progress. One case shows us the
disease at its beginning, another at a more onward stage,
another at its mid period, another towards its decline, another
at its end; and then joining together the facts so collected from
man!/ individuals, we get our notion of what the disease may
be in its entire course and character, from first to last.

Thus, of chronic injuries of the valves of the heart and
chronic adhesions of the pericardium, and their residts, you
must not expect that I can give you the same sort of account,
or attest it by the same sort of experience as I have j ust given
and attested of the acute diseases from which they sometimes
spring. I have spoken of endocarditis and pericarditis, and
their results in 90 cases which I had watched from first to last.
From first to last, however, was in them a period of a few
weeks only. But surely I cannot speak in like manner of
chronic injury of the valves of the heart, and of chronic adhe-
sions of the pericardium, and give results drawn from an observa-
tion of 90 cases from first to last. Yet have I seen ninety,
and many more than ninety, individuals, who have suffered
chronic valvular injury, or chronic adhesion of the pericardium.
I have seen, indeed, an infinity of patients; but in each patient
I have not seen the whole disease, but only a fragment of it,
and generally a very small fragment. Such single cases, in
their entire clinical history from first to last, occupy years;

LECT. VIII.] RESULTS OF ENDOCARDITIS, ETC. 95

some two or three, some five or ten, some even twenty or
thirty ; and of these the conditions of medical experience can
only allow a partial observation. Nevertheless, such partial
observations in process of time sum themselves up to a large
amount of knowledge, and furnish collectively a tolerably com-
plete clinical history of the diseases in question.

96 CLINICAL MEDICINE. [lECT. IX.

LECTURE IX.

ikflajNimation of the lungs accompanying acute rheuma-
tism, EITHER ALONE, OR IN COMBINATION ^VITII ENDOCARDITIS,
OR WITH PERICARDITIS, OR WITH BOTH.

When our business is witli a mere dead specimen of morbid
anatomy, it does not signify bow exclusively we view it. We
may take it apart, and look at it tbrougb a microscope, and dis-
sect and inject it and macerate it; and thus we may learn all
that can be learnt about it. But when we are concerned with a
living specimen of disease, if we would understand it, we must
deal with it after a different manner. The living disease, while
it works its own changes in the part it occupies, gives and
receives influences and impressions to and from other parts, and
to and from the constitution at large. Therefore, in order fully
to understand it, our enquiries must be enlarged in proportion
to it. They must reach as far as it reaches. They must not
settle upon the one single object, but be carried into many
things beyond it.

Our present subject is the heart and its diseases ; and what
we have now especially in hand to illustrate is the inflammation
of its lining and investing membranes which accompanies acute
rheumatism. But the heart is not the only vital organ liable
to suffer inflammation in acute rheumatism. The lungs may
suffer also ; the lungs, in all the several structures of which
they are composed. And the diseases which result are bron-
chitis, pneumonia, pleurisy.

Knowing, then, the relative dependency of function between
the two organs, and finding both ready to suffer alike from the
same pre-existing or co-existing disease of the constitution,
however our present business may be professedly with the one,
we must not refuse to let in whatever light may be reflected
upon it from the other.

It is not possible to make too much of those diseases of the

LECT. IX.] INFLAMMATION OF LUNGS WITH IIIIEUMATISM. 97

heart which arise out of rheumatism. But it is very possible to
make too little of the diseases of the hmgs which acknowledge
the same origin. The truth is, wo have done so. The very-
habit of dwelling long and minutely (as we needs must if we
would understand them) upon the facts which concern the patho-
logy of the one organ has brought us unconsciously to regard it
as a single centre of disease much more than it really is. It is
well to be aware of so natural a bias towards error, and care-
fully to guard against it. Let each fact be made to carry with
it the full force of its own truth, and yet, in relation to other
facts which are as true as itself, let it hold no higher value, place,
or proportion, than nature has given it.

Inflammation of the heart is incident to acute rheumatism,
and so too is inflammation of the lungs. The former is of more
frequent, the latter of more rare occurrence. Of 136 cases of
acute rheumatism, the heart was inflamed in 90, or in two- thirds
of the whole ; while the lungs were inflamed only in 24, or one
in5i.

But that inflammation of the lungs, notwithstanding its com-
parative infrequency, is a matter of no mean importance in
connection with acute rheumatism, will be seen from the form
and character it bore in the 24 cases.

I use inflammation of the lungs as a general expression for
inflammation of any pulmonary structure, either for bronchitis,
pneumonia, or pleurisy. The 24 cases in question were
made up of 4 of bronchitis, 18 of pneumonia, and 2 of
pleurisy.

Now a bronchitis, a pneumonia, or a pleurisy involves much
or little peril according to its circumstances. But here, which-
ever disease occurred, it always put on a serious character,
either from its mere magnitude and extent, or from its force of
morbid action, or from the stage at which it ultimately arrived.
In the four instances of bronchitis the afiection was no mere
catarrh, but an inflammation largely difiused through both
lungs, producing deep oppression and dyspncea. Of the two
pleurisies, one was single and the other double. The single
pleurisy produced a large efiusion into one side. The double
pleurisy produced a double hydrothorax. Of the 18 instances
of pneumonia, in 9 the disease was of one lung, and in 9 it was
of both.

r

98 CLINICAL MEDICINE. [lECT. IX.

Pneumonia, if it be severe and abiding, generally includes
more than its name implies. How much more we can often only
suspect, but not exactly tell, during the life of the patient, so
entirely do the pneumonic symptoms transcend the symptoms
of the concomitant disease, and in effect obscure them.. Severe
pneumonia will often veil a pleurisy as severe as itself. It was
suspected of doing so in several of the cases in question; and,
in one case, dissection at last disclosed double pneumonia with
double hydrothorax.

Such forms of pulmonary inflammation are portentous ingre-
dients in the clinical history of acute rheumatism, and give a
fearful interest to it. But what if this fearful interest be
further augmented by its frequent coincidence with inflamma-
tion of the heart ?

Of the 136 cases of acute rheumatism which form the basis
of our inquir}'-, inflammation of the lungs was found in 24,
Here the proportion is about 1 in 5|. But Jioic were these 24
cases distributed ? "What proportion of them occurred where
the heart was unaffected, and what proportion where the heart
was inflamed ? And, again, what proportion, where the inflam-
mation was of the endocardium alone; what, where it was of the
pericardium alone ; and what, where it was of the endocardium
and pericardium simultaneously ?

Of the 46 cases of acute rheumatism in which the heart was
unaffected, the lungs were inflamed in 5. Here the proportion
is as one to nine. But of the 90 cases in which the heart was
inflamed, the lungs were also inflamed in 19. Here the pro-
portion is more than one in five.

The 19 instances of inflammation of the lungs were distri-
buted amons" these 90 cases of inflammation of the heart in
different proportions, according to the part of the organ affected.

Of the 63 cases of endocarditis the lungs were inflamed in 7.
Here the proportion is as one to nine.

Of the 7 cases of pericarditis the lungs were inflamed in 4.
Here the proportion is more than one-half.

Of the 11 cases of endocarditis and pericarditis simulta-
neously, the lungs were inflamed in 8. Here the proportion is
more than two-thirds.

What can we, or what can we not, conclude from this enume-
ration of facts ? "What general truths do they declare ?

LECT. IX.] INFLAMMATION OF LUNCiS WITH RHEUMATISM. 99

We cannot conclude, from inflammation of the lungs being
found in one case of acute rheumatism out of nine, that acute
rheumatism has any strong natural tendency to inflame the
lungs. Neither can we conclude, from its being found in one
case of rheumatic endocarditis out of nine, that rheumatic
endocarditis has a special natural connexion with inflammation
of the lungs. The probability of inflammation of the lungs
arising out of acute rheumatism is small ; and the probability
is not at all augmented by its alliance with endocarditis. For
in acute rheumatism, inflammation of the lungs does not occur
more frequently when the endocardium is inflamed, than when
the heart is entirely exempt from disease.

We find it to be between inflammation of the pericardium
and inflammation of the lungs, and between inflammation of
the endocardium and pericardium occurring simultaneously in
the same subject, and inflammation of the limgs, that frequent
coincidence seems to establish a natural connexion.

That inflammation of the heart which is least perilous in itself
is least liable to have its danger augmented by an union with
inflammation of the lungs, viz. endocarditis ; while that which
is most perilous in itself is most frequently accompanied by
inflammation of the lungs, adding immensely to its danger, viz.
simple pericarditis, or endocarditis combined with pericarditis.

Of rheumatism without affection of the heart there
were : —

Cases 46. — Lungs affected in 5.

Single pneiunonia (fatal) M. 26. 26.

Single pneumonia M. 27. 81.

Single pneumonia W. 21. 111.

Diffused bronchitis ending in double pneumonia M. 30. 65.

Diffused bronchitis of both lungs . . . W. 24. 149.

Of rheumatism with endocarditis there were : —

Cases 63. — Lungs affected in 7.

Double pneumonia M. 27. 227.

Double pneumonia W. 25. 42.

Double pneumonia "W. 26. 65.

Diffused bronchitis passing into double pneumonia W. 20. 216.

Single pneumonia M. 27. 142.

Diffused bronchitis of both lungs . . . M. 24. 178.
Bronchitis passing into inflammation of the

larynx and trachea W. 21. 130.

M. 32.

166.

W. 25.

183.

^Y. 22.

110.

y and

M. 31.

140.

M. 26.

44.

M. 30.

107.

e lung

M. 25.

29.

M. 25.

69.

100 CLINICAL MEDICINE. [lECT. IX.

Of rlieumatism with, pericarditis there were : —

Cases 7. — Lungs affected in 4.

Double pneumonia M. 31. 121.

Diffusedbroncliitispassingintodoubleimeumonia M. 29. 60.

Single pneumonia W. 22. 4.

Single pneumonia W. 25. 121.

Of rheumatism with endocarditis and pericarditis combined

there were : —

Cases 11. — Lungs affected in 8.

Double pleurisy with-double liydrotliorax
Single pleurisy with hydrothorax
Double pneumonia ....
Double pneumonia with double pleurisy and

double Lydrotborax (fatal) .
Single pneumonia ....
Single pneumonia ....
Pneumonia and diffused bronchitis of one

(fatal)

Diffused bronchiti?. of both lungs (fatal)

I know not how I can give you a better notion of what these
complications really are, and how they present themselves one
after another to clinical observation, and the awful amount of
disease that results, than by describing, with some detail, certain
cases of acute rheumatism in which they existed, and comment-
ing upon their particulars as I go along.

William Buckley, a stout well-formed man of forty years of
ace, was admitted into St. Bartholomew's October 27, 1836.
He was suffering acute rheumatism, and complained of pain,
chiefly in his right shoulder and his right wrist, which was very
red and much swollen. His skin was very hot, his pulse ninety-
six and hard and full, his urine scanty and high-coloured, his
tongue covered with a thick moist white fur. He was thirsty,
without appetite, and sleepless at night. But withal his coun-
tenance was good and quite free from anxiety ; in short, it was
the coTintenance of health. He had no internal pain whatever,
and the sounds of his heart were perfectly natural.

Now this man was habitually healthy, and had never
suffered acute rheumatism in his life. His present attack was
from accidental exposure to cold, ten days ago, which was
followed by chilliness, heat, perspiration, and pain. The pain
began in his feet, passed to his ankles, and had already visited

LECT. IX.] INFLAMMATION OF LUNGS WITH RHEUMATISM. 101

all his joints in their turn, and been accompanied with heat and
swelling in all.

This case surely promised well, and I was content to treat
it with ten grains of Dover's powder night and morning, and
to interpose the use of active purgatives.

Tor three entire days, and four entire nights, his existing
symptoms remained nearly the same, and no new symptoms
were superadded.

On the fourth day the pain and swelling had shifted from
the right wrist and shoulder to the left wrist and shoulder.
And now, in applying the stethoscope to the region of the
heart, a distinct exocardial murmur was heard. It was chiefly
at the basis, and lost somewhat of its intensity as the instru-
ment was moved towards the apex.

Here was unquestionable pericarditis. And let me remark
that auscultation was regularly made of this man's chest day
by day, and was just as much a matter of course (the case
being one of acute rheumatism) as feeling his pvilse, or looking
at his tongue. The disease was not sought after from the
patient's drawing attention to the part by any complaint of
pain or unusual sensation, or palpitation. And when the
disease was found, the patient, in answer to all our questioning,
still declared himself quite unconscious of any thing amiss
within his chest. It was the fourteenth day of the rheumatism
that the pericarditis was first discovered, and it was most pro-
bably discovered as soon as it began to exist. But to proceed
with the case : —

The patient being a strong man, and his pulse being now
more full and hard, and his fever more fully developed, and a
vital organ inflamed, was bled by venaesection to twenty ounces,
and ordered three grains of calomel, and a quarter of a grain
of opium, every three hours.

The next day the general symptoms being the same, and
the exocardial murmur unaltered, he was bled again by venae-
section to eight ounces, and four ounces more were taken by
cupping from the prsecordial region, and the calomel and
opium were still continued.

The next day he had more power of moving his limbs, and
the to and fro sound was thought to be a little less distinct.

The next day the fever continuing fuUy developed, and the

102 CLINICAL MEDICINE. [lECT. IX.

pulse full and hard, and the murmur as distinct as ever, and
the calomel haying been now taken every third hour for four
days and four nights, and having not yet produced the least
sensible foetor of the breath or salivation, ten ounces more of
blood were taken from the arm.

And now for the four following days there was a great fluc-
tuation of all the symptoms. The pain in the joints abated and
returned, and then abated again. The pulse became less full
and hard, but more frequent. He slept well one night, and ill
another. The heart gave out a confusion of sounds which was
indescribable. It was doubtful whether salivation was not
coming on. Accordingly, for these four days, all active treat-
ment was suspended, while the course and tendency of the
symj)toms were carefully watched.

The four days ended, it was evident that a new disease had
arisen, and been added to that which already existed. The
endocardium was inflamed, as well as the pericardium. It was
the rise of the auscultatory signs proper to the new disease
that had produced the confusion of sounds. But now the
sound of endocarditis was more evident than that of pericar-
ditis. The single systolic bellows -murmur was very distinct,
while the to and fro sound had degenerated into a mere crump-
ling. Probably the pericardium was beginning to adhere.

The general state of the patient betokened great debility
and distress of the nervous system. The pulse was 120, and
small and soft. But this remarkable circumstance deserves to
be especially noticed, that although the pericarditis had been
going on ten days, and endocarditis was now superadded to it,
the patient had not been all along, and was not even now,
conscious of the least pain in the region of the heart. The
first symptom directly referrible to the heart within his own
consciousness, had arisen during the last two days. This was a
palpitation whenever he turned quickly round in bed.

And now the treatment was resmned by the apj)lication of
eight leeches to the prsecordial region, and the same dose of
calomel and opium at the same intervals as before ; for the sus-
picion of salivation was fallacious.

During the five following days, the symptoms continued to
fluctuate more and more. The constitutional sympathy was
transferred more and more from the vascular system to the

LECT. IX.] INFLAMMATION OF LUNGS WITH KHEUMATISM. 103

nervous system. The to and fro sound entirely ceased, and the
single systolic bcUows-munnur alone remained.

And now it was evident that another new disease had arisen.
At the lower part of the left lung a minute crackling had taken
place of the respiratory murmur, which too surely denoted
pneumonia.

Again, suspected ptyalism admonished us to suspend the
use of calomel ; and again it was resumed, when no ptyalism
was apparent. Still there was no praecordial pain. But still
the pain and the swelling returned, and receded capriciously to
and from the knees and the wrists.

In three days more the symptoms were all concentred in the
nervous system, and all the treatment consisted in the adminis-
tration of ojiium and ammonia. The pulse was very frequent
and very feeble ; the tongue trembled ; the hands trembled ;
there were frequent perspirations ; there was neither endocar-
dial nor exocardial murmur, or any other definite sounds of an
unnatural kind proceeding from the heart. Probably it could
not contract with force enough to produce them. There was a
mere roughness accompanying its systole.

Still life continued seven days longer. In the meantime
the pulse rose to 140, and became more and more feeble ; the
perspirations were more profuse, and almost continual ; the
tremblings of the limbs never ceased, and at length became
convulsive spasms. His mind wandered all day, except when,
his attention being strongly roused, he was brought for a short
time to himself. At night he was sleepless, singing, or mut-
tering, or vociferous. Opium, however, procured him sleep
during one entire night. He woke refreshed, was rational for
a short time, confessed he was free from pain, and then relapsed
into delirium. His evacuations passed involuntarily. As his
sweats became more copious, his tongue became drier.

At length he seemed made quiet by exhaustion. His last
two nights were very tranquil. On the 26th of November he
died. It was the fortieth day from the commencement of the
rheumatism, the twenty-sixth day from the commencement of
the pericarditis, the eighteenth or nineteenth from the com-
mencement of the endocarditis, and the fifteenth or sixteenth
from the commencement of the pneumonia.

The exocardial murmur was distinctly audible only seven

104 CLINICAL MEDICINE. [lECT. IX.

days, and in nine days it was entirely gone. Hence we inferred
that the pericardium was adherent to the heart. The endocar-
dial murmur ceased as such in eight days, from the heart
having not force of contraction enough to produce it, and so it
degenerated into a mere roughness. The crepitation, which
denoted the lungs to be inflamed, being once heard at the back,
was never afterwards sought after ; for it would have been at
peril of the patient's life to have raised him in bed, his debility
had become so great.

There is an omission of one important circumstance in the
record of this case. I find no notice of any dulness to per-
cussion in the praecordial region. In truth, I was not at that
time (1836) fully aware of the important intimations derived
from percussion in pericarditis.

Now, why was not this man cured ? When he came into
the hospital his complaint was simply rheumatism, and each of
its perilous adjuncts arose one by one under our observation,
and was treated vigorously and without delay. The man's
constitution, too, was good, and capable of bearing well the
remedies needed to arrest the progress of inflammation. Yet
he died. Did he die because the great remedy failed of its
specific efiect, — because the mercury failed to salivate? The
appearances on dissection appertaining to the heart will be
found elsewhere.* The following was the state of the lungs.
Both of them were slightly emphysematous, and neither of
them collapsed upon removal of the sternum. The right was
crepitous throughout, and loaded throughout with frothy san-
guineous fluid ; and the surface of every bronchus, as far as it
could be traced, was loaded with blood. Every portion of this
lung was buoyant in water. Of the left lung the entire lower
lobe was hepatised, and sank in water while the upper lobe
presented the same pathological conditions as the other lung.

To me this case, as it passed under my observation, was full
of interest and instruction, and of painful disappointment.
(M. V. 25, p. 29.)

Catherine Sullivan, aged 22, married, a picture of abject
want and wretchedness, was admitted into St. Bartholomew's,
May 4, 1837. Her skin was hot and perspiring, her pulse 120,
and full, but without power, and occasionally faltering in its

* Vide p. 92,

LECT. IX.] INFLAMMATION OF LUNGS WITH RHEUMATISM. 105

beats. All her larj^c joints swelled and painful ; licr breathing
now quick and hurried, now pausing and sighing. She com-
plained, moreover, of pain in the prsecordial region, and pal-
pitation. She coughed often, but did not expectorate, and in
coughing she increased the pain at her heart.

Auscultation found the exocardial murmur most distinct at
the basis of the heart, and extending thence to the cartilage of
the fifth rib. It found, also, the systolic endocardial murmur,
which was, also, loudest at the basis, and gradually became less
loud towards the apex.

Such was her actual state. And this was her history. She
had lived in vice and misery, and want. Ten days ago she
had begun to suffer pain and swelling of the joints with fever.
From the first she had been sensible of indefinite pain and
uneasiness of the chest, which two days ago, by gradual in-
crease, had reached their present form and aggravation.

It is hardly possible to conceive a case more unpromising
than this. Here were the worst diseases in the worst constitu-
tion. They had been in progress probably for more than a week.
They had probably reached their extremity two days. The
pericarditis and endocarditis and the rheumatism had been
hitherto untreated by any remedy. All still remained to be
done that could be done.

She was at once cupped to ten ounces between the left
scapula and spinal column, and ordered to take two grains of
calomel and a quarter of a grain of opium every three hours.

The next day she was found to have passed a quiet night,
though without sleep. But her pulse had risen to 140, and
was certainly feebler. The proccordial pain had increased, and
the palpitation and dyspnoea were undiminished. The same
sounds were heard in the region of the heart. She had had
three or four bilious motions.

Thus the change since yesterday was surely for the worse.
The greater weakness and greater frequency of the pulse
denoted that a collapse of the nervous system was at hand.
But one symptom there was, which, among all others that were
bad, still furnished me a ground of hoiDe. The tongue was
covered with a white fur, and was very moist. This seemed to
promise a speedy salivation.

She was again cupped between the left scapula and the

106 CLINICAL MEDICINE. [lECT. IX.

vertebral column to ten ounces, and the calomel and opium
were continued as before.

The next day, the endocardial and the exocardial murmurs
being the same, and the pulse being just as feeble and frequent
(140) as it was, the cough, and palpitation, and proocordial
pain, and pain in the joints were all diminished. The gums
were slightly sore.

On the next day the pulse and all the general and local
symptoms were the same, while the salivation was on the
increase. But on the next the countenance manifestly less
anxious, and the pulse reduced for the first time to 120, bespoke
some favourable change in the essential conditions of the
disease, although the auscultatory signs were yet unaltered.
But it was deemed right still to give the calomel and opium
every four hours, for the salivation was not yet profuse.

It was now the 8th of May, the fourth day since the
patient's admission. There was a remission of all those
symptoms which denote progressive disease, and an apparent
possibility of saving her life. This remission, however, only
lasted two days. For on the 10th of May the pulse again rose
to 140 ; the dyspnoea returned with pain in every part of the
chest, as much on one side as the other, and before as behind.
Auscultation found large and small crepitation diifused through
both lungs. There was double bronchitis and double pneu-
monia. The weakness was now so extreme, that no form of
bleeding could be thought of. A large blister was ajjplied to
the sternum, and the calomel and opium continued.

The next day the dyspncea had become an indescribable
anguish and struggle for breath. On the next the same dis-
tress continued, when auscultation found the right side of the
chest entirely dull to percussion, and no air entering into any
part of the right lung, except at a small space opposite the
scapula, where there was the loud puffing of bronchial respira-
tion, and the bronchial voice, which amounted to pectoriloquy.
I suspect the right pleura had become suddenly filled with
fluid. The left lung still admitted air everywhere, but every-
where with a crepitation. As to the heart, the endocardial
murmur had entirely ceased, and the exocardial murmur
remained alone.

A short description will suffice for the four following days

LECT. IX.] INFLAMMATION OF LUNGS WITH RHEUMATISM. 107

Salivation had run on to an excessive degree, and produced its
worst distress. The fauces swelled, the tongue became too
large for the mouth, and a stream of saliva was continually
running from it. None but the erect posture could be borne
night or day. The respirations were never less than 50 in a
minute, or the pulse than 135. She was speechless, and when
inquiry was made of her pains, she pointed to the epigastrium
and right hypochondrium as their seat.

In this state of things there was no room for further treat-
ment. One great remedy, the mercury, though it was no
longer given, was still in constant and unrestrained operation.
In truth neither food nor medicine coidd be administered
during these four days. Neither was it possible to make any
effectual examination of the chest from fear of killing her if
we disturbed the only posture in which she could breathe.

On the 15 th of May, being still alive, a large blister was
applied to the seat of pain, which she indicated in the epigas-
trium. On the 16th she gave signs that her pain was relieved;
her pulse had fallen to 120 ; her countenance had lost some of
its distress ; the breathing was less difficult, and she could lie
on her back.

The next three days and nights were a period of comfort. No
pain was felt. The respiration was easy and much less frequent,
and there was hardl}'' any cough. The pulse had come down
to 120. The salivation and all its attendant distresses were
greatly lessened. Yet there remained still some pain in the
limbs. The endocardial murmur again accompanied the systole
of the heart, but the to and fro sound had entirely ceased. I
could not bring myself to disturb her tranquillity by raising her
in bed for the purpose of learning, by auscultation, the state of
the lungs.

Now there was a fair hope that the work of reparation had
begun, and that it would proceed without further interruption ;
but on the 19th it was found that such pain in the chest and
dyspnoea had come on during the night as to prevent her lying
or sleeping. She was still in the erect posture, and the pain
and dyspnoea continued, and the pulse had run up to 140. The
whole of the right side was absolutely dull everywhere as it
was when the last auscultation was made. I ventured to draw
a few ounces of blood by cupping glasses apj)lied to the back

108 CLINICAL MEDICINE. [lECT. IX.

below the right scapula ; and ordered two grains of calomel
and a quarter of a grain of opium to be taken that night and
the next morning.

The next day the dysj)noea was greatly diminished, and the
pain within the chest was entirely gone. From this time conva-
lescence proceeded slowly, but uninterruptedly. On the 30th
the left lung had altogether recovered its healthy condition, and
a feeble respiratory murmur was heard in every part of the
right.

The patient remained in the hospital several weeks longer,
gradually recovering all the general conditions of health. She
left the hospital with the right lung restored almost to an equal
capacity of breathing with the left, and the endocardial mur-
mur still accompanying the systole of the heart, and the
exocardial murmur gone. (W. 22, p. 110.)

LECT. X.] TREATMENT OF ACUTE RHEUMATISM. 109

LECTURE X.

THE TREATMENT OF ACUTE KHEUMATISM CONSIDERED, TREPARA-
TORY TO THE TREATMENT OF ITS ACCOMPANIMENTS, ENDOCAR-
DITIS AND PERICARDITIS. — ACUTE RHEUMATISM SUCCESSFULLY
TREATED, UPON DIFFERENT AND EVEN OPPOSITE INDICA-
TIONS, AND BY DIFFERENT AND EVEN OPPOSITE REMEDIES.

HOW THIS MAY BE WITHOUT DISPARAGEMENT OF MEDICINE

AS A SCIENCE. THE TREATMENT OF ALMOST ALL CURABLE

DISEASES NARROWED TO THE CHOICE OF A FEW INDICATIONS
AND A FEW REMEDIES. — WHAT THE LOWEST AND WHAT THE

HIGHEST OFFICE OF THE PHYSICIAN. THE HIGHEST ENGAGED

IN THE TREATMENT OF ACUTE RHEUMATISM AND ITS INCI-
DENTS. THE GROUNDWORK OF RATIONAL PRACTICE IS TO

UNDERSTAND THE VALUE OF SINGLE INDICATIONS, AND THE
POWER OF SINGLE REMEDIES. TREATMENT OF ACUTE RHEU-
MATISM UPON INDICATIONS BELONGING SOLELY TO THE
VASCULAR SYSTEM, AND SOLELY BY BLEEDING. — UPON INDI-
CATIONS BELONGING SOLELY TO THE NERVOUS SYSTEM, AND

SOLELY BY OPIUM. UPON INDICATIONS BELONGING SOLELY

TO ABDOMINAL VISCERA, AND SOLELY BY CALOMEL AND
PURGATIVES.

All our inquiries, as far as tliey have gone, into the subjects
of endocarditis and pericarditis may be very interesting, and
all our speculations may be just and true. But however
interesting, just, and true, they must not terminate here. Our
patients at least have a farther concern with these diseases, and
so should we — a concern, namely, how they are to be treated.

Now, endocarditis and pericarditis are the same things in
essence. They are both inflammations. And endocarditis and
jjericarditis are annexed to the same pathological condition of the
constitution at large. They both belong to acute rheumatism.
Moreover, they often occur together in the same subjects.
Thus the treatment of both is by the same remedies, and may
be spoken of together.

110 • CLINICAL MEDICINE. [lECT. X.

But the treatment of the general pathological condition out
of which they both spring, first claims our attention. For the right
or wrong management of the rheumatism may have a share in
determining whether these, which for the present we must be
content to call its incidents, shall or shall not take place at all.
And further, if they do take place, what shall be their character,
and what their degrees of severity.

Acute rheumatism has experienced strange things at the
hands of medical men. No disease has been treated by such
various and opposite methods. Vena3section has wrought its
cure, and so has opium, and so has calomel, and so has colchi-
cum, and so have drastic purgatives. I speak of these remedies
in the sense which medical men imply when they talk (as they
sometimes do) of this, that, or the other thing being their
" sheet anchor "; meaning that they rest upon it alone for the
cure of the rheumatism, and employ other remedies either not
at all, or for very subordinate purposes. And, indeed, I bear
my testimony to the success of each of these different remedies,
so far as that, under the use of each, I have seen patients get well.

At the first view all this looks very strange. The cure, or
seeming cure, of the same disease by different remedies, even
by remedies which in their mode of operation have nothing
in common, appears like luck or accident. At the first view it
may shake one's faith in physic a little, and may a little excuse
the pleasantry of some who choose to hint, that Nature is our
best friend after all; for that, do what we will, she brings
things to a prosperous issue in spite of our blind interference.

But without disparaging the part that Nature plays, I here
see no fair subject of ridicule, and no fair reason for distrust of
methods of rational treatment. The first maxim of all rational
practice is, that Nature is supreme ; the next, that Nature is
obsequious. The end, whether bad or good, death or recover}^,
and every step and stage conducive to it, are the unquestionable
work of Nature. But Nature, in all her powers and operations,
allows herself to be led, directed, and controlled. And to lead,
direct, or control for purposes of good, this is the business
of the j)hysician. But how to do it best, he has to exercise a
choice of modes and means in every case, which, though never
exempt from the possibility of error, becomes less fallible by
the teaching of experience.

LECT. X.] TREATMENT OF ACUTE RHEUMATISM. Ill

Tliis choice leads, and always will lead, to diversify of
practice, which in no way disparages, but rather tends to
enlarge and to enrich the resources of our art.

It is not possible that the treatment of diseases shall be ever
set at rest by the consent of physicians, or that fixed and uniform
plans and remedies shall ever be adopted in cases bearing the
same nosological name and character. At least it cannot be
until each disease has its own specific antidote, or until each has
disclosed some seminal principle from which it springs, and
shown where it is, and what it is : some principle, too, it must
be which is within reach, and which is destructible and easily
destroyed.

But we know very little about the seminal principle of
diseases, and that little serves to show that no sooner does it
enter the body (as in the case of contagion), than it is gone at
once beyond our reach. It germinates in secret. It spreads
itself abroad in secret. And when, at length, it excites various
organs and systems to extraordinary modes of action and suffer-
ing, then, and not sooner, begins our knowledge of a present
disease, and our power of interfering with it. In truth, these
modes of action and suffering are to us the disease. They are,
moreover, our only objects of medical treatment.

In cases of fever from contagion, in cases of inflammation,
which is independent of external violence — spontaneous in-
flammation, as it is called — much must have been going on
covertly within the body before those modes of action and
suffering arise, which are plainly cognisable by us, and which
we can interfere with. But coming in with our knowledge and
our treatment when we do, and late as we may seem to do, we
are nevertheless soon enough with both to perform the jDroper
work of physicians, and to withhold the disease from terminating
in death or disorganisation. For it is by these actions and
sufferings — it is by the actions and motions of blood-vessels, or
by the feelings and susceptibilities of nerves, or by the special
functions of particular organs, such as the stomach and bowels,
the liver and kidneys, being extraordinarily exalted or extraor-
dinarily depressed, or variously disturbed and perverted, it is by
one or by several of these that diseases, of whose seminal prin-
ciple we have no knowledge, declare their existence, and denote
their progress and tendency ; and it is by and through the

112 CLINICAL MEDICINE. [lECT. X.

same that they are brought into a capacity of treatment and of
cure. The vascular system as a whole, and the nervous system
as a whole, and the particular organs indicated, are in an especial
manner within the reach and power of medicine. It is by
remedies operating through some of them that nearly all curable
diseases are in effect cured.

But our present business is only with the treatment of acute
rheumatism. Yet these general remarks, introductory to it, will
nofc, I trust, be thrown away. For the treatment of acute rheu-
matism, above all other diseases which can be named, is a thing
to put the physician and medicine itself to the trial of what they
can really do. Here are no specifics at hand. All proceeds
upon rational calculations ; upon the right choice of purposes
to be fulfilled, and the right choice of means to fulfil them.
Acute rheumatism is often such in itself and such in its
appalling incidents, as to need from time to time that medicine
should put forth the full compass of all its powers. Every
organ or system of organs which, either directly or indirectly,
can receive the impression of remedies, are from time to
time called to bear all that they can possibly endure ; and it is
often only when the powers of medicine are pressed even to the
verge of destroying life, that life is saved.

If the treatment of acute rheumatism ever come to this, it is
riffht to know what we are about when we undertake to treat it.

It has been said that, in the treatment of acute rheuma-
tism, one trusts entirely to venaesection and cures it, another to
opium and cures it, and another to drastic purgatives and cures
it. Here, among several indications which offer themselves to
his choice, the physician takes a single one, and makes it the
sole mark and scope of his practice, trusting that, when he has
effectually attained it, the complex actions and sufferings which
constitute the disease will be brought to an end.

Thus he takes the high vascular action of acute rheumatism,
and sees the whole disease represented in it, and is solely intent
upon subduing it by venisection, expecting that, as he pulls
down the circulation, the fever, the nervous disquietude, and the
pain, and the swelling will all cease, and the various secreting
organs of the body will resume their natural functions, and that
thus the actions of health will gradually supersede the actions
of disease. Or he takes the nervous disquietude and the pain of

LECT. X.] TREATMENT OF ACUTE RHEUMATISM. 113

acute rheumatism as the representative of the entire disease, and
deals with it accordingly, being solely intent upon moderating-
them with opium, and expecting that, as they subside, the high
A-ascular action and the fever and the swelling will subside along
with them, and that the secretions will return to their healthy
measure and kind. Or ho takes the state of the several secre-
tions, their deficient quantity, and their unhealthy quality, as
the rej)resentativc of the entire disease, and so addresses his
treatment to those organs whose secretory functions are more
immediately within the reach of medicine, to the stomach and
bowels and liver, and he gives large and repeated doses of calo-
mel, and follows them with large and repeated doses of purgative
medicine. This he does, and this is all that he does ; and
having done it effectually for a few days, and obtained very
large and bilious evacuations, he expects that the fever, and high
vascular action, and nervous disquietude, and pain and swelling
will all cease, and the patient will be well.

Ijet me repeat my testimony to the success of this practice
in acute rheumatism; the practice, namely, of choosing some
single indication, and steadily pursuing it to its fulfilment. It
is a very rational practice. It is founded upon experience, and
it compasses its end by very simple means ; and the manner of
its successful operation may be well conceived, if it cannot be
entirely explained, in the present state of our knowledge.
Disease is a series of new and extraordinary actions. Each link
in the series is essential to the integrity of the whole. Let one
link be fairly broken,' and this integrity is spoiled ; and there
is an end of the disease ; and then the constitution is left to
resume its old and accustomed actions, which are the actions
of health.

But, you may ask, Is the treatment of acute rheumatism
really so plain and simple an affair in all cases ? Is there
nothing else to be done, but out of several purposes (or indica-
tions of treatment, as we call them) to choose judiciously some
single one, and pursue it resolutely and effectually by the simplest
means? And is this the practice to which the cure of the
disease may be safely trusted in all cases? Certainly not — cer-
tainly in a small proportion of them only.

But it is not without reason that I have dwelt upon this
practice of single indications and single remedies. For, though

114 CLINICAL MEDICINE. [lECT. X.

capable of being strictly followed in a few cases only, it contains
a principle of large application, which helps and furthers the
treatment of aU cases of this disease, and of many diseases
besides.

The lowest office of medicine is to minister to mere ailments ;
and this is most effectually done by telling people what in their
ordinary mode of living is injurious, and warning them against
it. But inasmuch as injurious things are commonly very
pleasant things, people are reluctant to leave them ofi' at our
mere bidding. Hence in this, which is their humblest province,
small credit upon the whole has been gained by the best
physicians. The advice they have to give is much too simple
for the world to accept upon the credit and character of well
instructed and honest men. It needs to be enforced, not by the
art which they do practise, but by the mystery which they do
not. For no sooner does the same recommendation of abstinence
from what is injurious gain the help which it needs from the
mystery of homceopathy (a mere name, importing the discovery
of something unintelligible, and importing it for the popular
enlightenment in Greek) than compliance becomes easy, cures
multiply, fame vociferates, the glory is great, and great too is
the emolument.

But the highest office of medicine is to minister to diseases,
which, by themselves or by their incidents, go directly and
rapidly to the destruction of life. And this is not to be done by
begging peoj)le to be reasonable and abstain from what is wrong,
and cheating and cajoling them into compliance. But it is a
business for wise and cautious men alone to meddle with. The
powers of art must be brought to overrule the operations of
nature by force. To know these powers and how to wield them
to such a purpose is an affair beyond all trick and all skill of
practising upon the fancies of mankind. It can onl}^ proceed
from a faithful and candid search after truth by each of us for
himself according to his opportunities, and from a ready com-
munication of what we believe to be the truth by all of us
among one another, and from a comparison of their experiences
and conclusions among the best minds.

Now the highest office of medicine, in the sense explained,
is engaged in the treatment of acute rheumatism and its inci-
dents. At every step of its treatment, principles are involved

LECT. X.] TKKATMENT OF ACUTE RTTEUMATISM. 115

whicli may bo transferrccl to the treatment of almost all diseases
in which medicine plays an indispensable part. While, there-
fore, I proceed to tell you of the management of acute rheuma-
tism, you must consider me as illustrating the general power of
remedies by this example, and so be prepared for any general
remarks I may let in as I go along.

Well, then, I am persuaded that when the physician is called
upon to perform great things, even to arrest destructive disease,
and to save life, his skill in wielding the implements of his art
rests mainly upon the right imdcrstanding of simple and single
indications, and of the remedies which have power to fulfil
them. To know that, in any cases of acute rheumatism, the
cure of the entire disease is accessible through the blood-vessels
alone, by subduing their too forcible action ; or accessible
through the nervous system alone, by moderating its dis-
quietude, and abating pain ; or accessible through the stomach
and bowels and liver alone, by stimulating them to a very largo
amount of secretions ; and to know, moreover, that in any cases
vensesection alone will fulfil the first purpose, or opium alone
will fulfil the second, or calomel and aperients alone will fulfil
the third : to know all this is the best preliminary step towards
enabling us to deal safely and successfully with other and more
numerous cases, which need a more complex method of treatment,
and require that all these important purposes be pursued simul-
taneously, and all these great remedies be made confederate for
the cure of the disease.

As to the first of these great remedies, and the indications
for employing it, I know no disease in which febrile heat is
greater, and the pulse harder, fuller, and more forcible, than
in acute rheumatism. What, then, are the signals for copious
blood-letting, if these are not ? And together with heat sq
great, and the pulse so hard, so full, and so forcible, unques-
tionable inflammation is present in various parts of the body ;
and what can further demand and justify copious blood-letting,
if this does not ?

But let us pause and consider awhile. When inflammation
is unquestionable, and when it has newly arisen, and with it
fever and excess of vascular action, the amount of this fever
and vascular action becomes the measure of its treatment.
And it becomes so, because it is in truth the measure of the

116 CLINICAL MEDICINE. [lECT. X.

inflammation itself, i.e. the measure of its force, and the rate
of its progress towards whatever ci'il event it may tend, either
according to its own nature, or according to the nature of the parts
it occupies. In most parts of the body such an amount of fever
and vascular action, as usually accompanies acute rheumatism,
would denote inflammation tending rapidly to its worst event
— to some kind of destructive disorganisation. It woidd so
in the brain ; it would so in the lungs ; it Avould so in the
liver. Therefore, in inflammation of the brain, the lungs, or
the liver, such fever and such vascular action would call for
any quantity of blood-letting that might be needed to subdue
them. For their abatement alone would show the inflammation
abated, and its destructive progress arrested.

But in rheumatism the inflammation (I mean the external
characteristic inflammation), either from its own nature, or
from the structures it occupies, tends to no such destructive
event. It has its primary seat (there is reason to believe) in
fibrous structures, and the swellings which accompany it are
produced by serous efi'usion, partly into neighbouring cellular
texture, and partly into the synovial membranes of bursa) and
joints. And in the vast majority of cases, however severe
be the disease, and however long it may last, the local mis-
chief stops with these eflusions, and the structures engaged,
fibrous, cellular, and serous, undergo perfect reparation, and
the joints are eventually uninjured.

In acute rheumatism, therefore, the excessive heat, and the
full, hard, and forcible pulse need not hurry us into a deter-
mination to bleed to any amount that may be requisite to
subdue them, Avith the ultimate purpose of withholding the
inflammation from a destructive event. But the aim and in-
tention of the remedy are rather respective to the disease as
a whole, than to the inflammation attending it. It would be
otherwise if the liver, the lungs, or the brain were inflamed,
and not the joints.

With respect to the disease as a whole, then, let us consider
the uses of this remedy.

I have seen people enormously bled in acute rheumatism,
and their entire disease swept away at once, and health restored
rapidly. And the practice which will do this, is it not a
splendid and a tempting practice ?

LECT. X.J TREATMENT OF ACUTE IIHEUMATISM. 117

Again ; I liavc seen people enormously bled in acute rlicu-
inatisni, and llieir disease swept away at once ; but they liavc
ibrthwith g-one raving mad. .Vnd a practice wbich will do
this, is it not a hazardous practice ?

And again ; 1 have seen people enormously bled in acute
rheumatism, and no single pain has been mitigated ; but the
disease has continued for an unusually long time in its acute,
^ind then has degenerated into its chronic, form. And a prac-
tice that has this issue, is it not a doubtful practice ?

These facts are instructive. They warn us to beware of
large bleeding in acute iheumatism. Yet the immediate indi-
cations for it now, when it woidd (I believe) be erroneously
prescribed, are the same upon which it would be entirely justi-
fiable in some other diseases, viz. the extreme heat and the
extreme fulness and hardness of the pulse. But then in those
•other diseases, all hazards sink into insignificance compared
with the hazard of progressive inflammation in a vital organ.
Large bloodletting, however, has hazards of its own great
enough not to be incurred except in exchange for those which
are far greater.

Now, one chief hazard of large bleeding is from the shoclc
it is apt to communicate to the nervous system ; and it is thif>
which we should especially seek to avoid, when we employ
vena^section in acute rheumatism. Venisection is often needed ;
needed for what no other remedy can perform towards the
cure, and therefore not to be omitted. It is needed especially
to abate high vascular action. But no such thing must bo
thought of as bleeding and bleeding, until the large pulse
becomes small, and the hard pulse soft. For, to bring about
this, blood must be let flow to a terrific amount. Fulness and
hardness of pulse are indeed express characteristics of acute
rheumatism, rising to superlative degrees, and enduring perti-
naciously, and resisting stubbornly the power of remedies to
pidl them down. To abolish them at once or speedily in the
severer cases, is hardly possible by any counteracting means
which medicine can safely employ. They are above a match
for them all, and they trill endure their time. They are above
a match even for vena3section, unless it be pushed with a
desperate hand, careless and reckless of new dangers to life.

Upon the whole, then, the practice which proposes to

118 CLINICAL MEDICINE. [lECT. X.

compass the cure of acute rheumatism at whatever cost of
blood may be needed to fulfil the indication of absolutely
subduing the force of vascular action, is a very imcertain and
a very dangerous practice, although success has undeniably
attended it in some instances.

Still venoosection is among the remedies of acute rheuma-
tism, not needful in all cases, but expedient in many. It is
expedient to abate vascular action when it is excessive, and
when the patient is robust and young, and the disease has
arisen accidentally in a healthy constitution. And these,
indeed, are its most common conditions. Acute rheumatism
is most frequently found in the young, the robust, and tho
previously healthy. But however the severity of the disease,
and the age and constitution of the subject, may invite the
remedy, this caution especially must be observed in its use ;
take care that in abating vascular action by venisection, you
do not communicate a shock to the nervous S3\stem. If you do,
you are likely to disturb the just tenor of the disease, and then
some untoward circumstance, which is quite foreign to it, may
arise, and some of its worst events may ensue.

But in the young, the robust, and the previously healthy,
where vascular action is not excessive, and in the old, the
feeble, and previoiisly valetudinary, even where it is, veni-
section is best omitted. There are other remedies, which,
without the help of vena-section, may be trusted for its safe
and effectual cure.

Summarily then I would venture to say of venisection,
employed under the most suitable conditions, and in the most
suitable measure, that it is to be trusted, rather as preparatory^
and auxiliary to other remedies, than for its own exclusive
remedial power in acute rheumatism. It very often renders
the disease more curable by other means ; but it seldom cures
the disease itself.

But it has been said that the cure of acute rheumatism is
accessible through the nervous system alone, and by means of
opium.

No disease can be mentioned of which pain is a more promi-
nent and abiding characteristic ; hardly any in which it is more
severe and more extensive, and occupies more situations at a
time. It is, moreover, the sort of pain which rouses and excites,

LECT. X.] TREATMENT OF ACUTE EIIEUMATISM. 119

and however long it may continue, even for several weeks i)er-
liaps, it still rouses and excites to the last.

This is a circumstance which deserves our notice. The
pain which is annexed to inflammation of internal and vital
organs, however it may at first rouse and excite, soon begins
to depress, then to exhaust, and then to overwhelm ; and as
the disease proceeds, and as the vital powers fail, the nervous
system sinks into an absolute incapacity of feeling pain at all.
But the pain which belongs to the inflammation of external
parts and parts not vital, continues much longer to rouse and
to excite, becavise life itself, or the springs of life, continue
much longer unassailed. Thus, in acute rheumatism, the ner-
vous system and the vascular system, the great sources of action
and feeling, being unharmed, feel and resent the disease purely
as a stimulus. As long as the inflammation is of the fibrous,
cellular, and serous structures in the neighbourhood of joints,
and of them only, the brain and the nerves, the heart and the
blood-vessels, and all that feels and all that acts within the body,
have their susceptibilities and their movements raised, quickened,
and invigorated. All within the man is (as it were) doubly
alive; and every thing that hurts is doubly felt, and doubly
resented.

If, then, such be the pain, and such the long and undimin-
ished capacity of suffering in acute rheumatism, well might
physicians, in their treatment of it, look to such remedies as
abate pain, and exercise a sedative influence upon the nervous
system. They have, indeed, looked especially to opium. And
opium, prescribed with these intentions, has encountered the
disease singlehanded and successfully. But how prescribed,
and in ivhat measure ?

A grain of opium given to a man in health and at ease,
woidd continue to be felt for twenty-four hours ; not so when
it is given to a man in constant and severe pain. The same
quantity would now be felt little or not at all, or for a much
shorter time.

The nervous system may become wild with suffering, and
then it is not to be soothed and coaxed into quietude, but to be
subdued. It is with the nervous system exasperated by phy-
sical, as it is with the mind exasperated by moral, pain. The
maniac cannot be pacified by persuasion ; he must be held

120 CLINICAL MEDICINE. [lECT. X.

down by some power which he cannot resist ; and even then
he is not absolutely still. The victim of cancerous disease must
be overpowered and stupified with opium, and even then he is
not altogether insensible to his pain.

The pain of acute rheumatism will hardly bear to be com-
pared with that of cancer. But it is a very sharp and constant
pain, and severely aggravated by the least movement and the
least touch. The dose of opium must be large, and pretty
often repeated, which is to reach it and lessen it. In the
severer cases, and when the whole treatment of the disease is
left to the sole remedial power of opium, the measure and fre-
quency of its dose must be enough to subdue, if it is to have a
fair chance of tranquillising.

When iirst, and for a few years after, I became j)hysician
to an hospital, opium was my remedy in all cases of acute rheu-
matism, excepting such as presented some special circumstance
to forbid its use, or to require a different treatment. My single
purpose was to abate pain, and to quiet the nervous system.
The dose I employed varied from two grains to five or six in
twenty-four hours. I began with one grain every twelve hours.
Then, as the patient seemed to bear it or to need it, I gave a
grain every eight hours, then every six, and then as often as
every four. There were many cases for which a grain every
twelve hours, or two grains in the twenty-four, were quite
enough. And there were few for which a grain every four
hours, or as much as six grains in the twenty-four, were needed.
The majority, however, required a grain every eight or eveiy
six hours, or three or four grains in the twenty-four. In the
mean time, while I thus employed opium immediatehj to abate
pain and quiet the nervous system, and ultimately to cure the
disease, I had no other care except to keep the bowels from
being bound, but not to purge them.

And now, perhaps, you may be disposed to suspect, after aU,
that this practice had nothing positiveij^ remedial in it ; that
the progress and duration of the disease were in nowise affected
by it ; and that only its pains were thus rendered more tolerable,
while it wore itself out by a spontaneous and unassisted reparation.

But I am very far from thinking so. It is true that I cannot
produce a certain number of cases treated by no remedy at all,
and compare them in their results with a certain number of

LEU'r. X.] TREATMENT OF ACUTE RHEUMATISM. 121

cases treated by opium. I do not know that I over saw a case
of acute rheumatism left entirely to itself. But I have seen
many cases, if not altogether abandoned to nature, very little
assisted by art. When I was a student, acute rheumatism in
the hospitals of London was commonly treated thus : — A dose
of liq. ammonia acetatis was given thrice in the twentj^-four
hours, and a moderate opiate at night. Such treatment cannot
be called nugatory, or tantamount to no treatment at all. It
might even, where pain and vascular action were small, have
been quite treatment enough, and have justly had the credit of
the cure. But in the majority of cases it could have done very
little. In the majority there was more of action and suffering
than it coidd have j)Ower to counteract. The means themselves
had no unsuitableness to their end; but there was a shortcoming
in the way of using them. The means had plenty of remedial
force in store ; but that force was not brought out, as it might
have been, by the time and measure of their application, and so
made more a match for the force of the disease, and more
available for its cure. Accordingly, by this treatment (to speak
of its results as favourably as possible), the acute rheumatism
was seldom brought to a close in less than six weeks. It took
full six weeks, upon an average, to get the patient out of bed
and fairly upon his legs again. And then he had still his
strength to regain that he might be fit for work. Whereas,
under the treatment by opium (given not merely in a moderate
dose and at night only with the hope of procuring sleep, but at
more frequent intervals and in quantity proportionate to the
amount of pain and nervous disquietude it had to subdue or to
mitigate) the disease has commonly ended, and convalescence
has fairly begun in half the time.

Such, then, is my experience of the curative impression,
which may be conveyed to the entire disease solely through the
nervous system, and solely by means of opium. And let me
add that, considering what acute rheumatism is in the majority
of cases, and what it needs, and what it will bear, I regard the
indication found in the nervous system to be upon the whole a
safer and better guide for its treatment than that found in the
vascular, and opium uj)on the whole to be a safer and better
remedy than vensesection ; if we are to follow one of the two
indications, and to use one of the two remedies only.

122 CLINICAL MEDICINE. [lECT, X.

But recollect, I am not recommending that acute rheumatism
be treated exclusively, either according to the one or the other of
these indications; or exclusively, either by the one or the other
of these remedies. I am only now showing the value of each
indication, and the power of each remedy separately, in order
that you may better understand and apjireciate other more
complex methods of treatment in which both indications are
followed, and both remedies are employed concurrently.

The third plan remains to be considered, which, passing by
the vascular system and the nervous system and all indications
of treatment to be found in either, fixes upon the liver and the
abdominal viscera, and seeks to compass the cure of the entire
disease by remedies addressed solely to them.

The immediate object of this practice is to obtain from these
organs a vast augmentation in the amount of fluids which they
secrete, and to evacuate it outwards. The mode of proceeding
is this. Ten grains of calomel are given at night, and a draught
of salts and senna on the following morning; and the same are
repeated night and morning as long as they are well borne, and
continue to produce the effect desired.

The evidence of their being well borne is, that they occasion
little or no distress in their operations ; and the efiect desired is,
that they bring away abundance of a dark or deep-coloured
bilious colluvies from the bowels. As long as such are the
feelings of the patient under their operation, and such their
efiects, the medicines may still be given, and still are needed.

The evidence of their being ill borne is that they occasion
tormina and tenesmus, and scalding of the rectum; and their
effect not to be desired is, that they bring away pure bile, or
transparent mucus or blood. When such begin to be the
patient's feelings, and such the products of the medicines, this
plan of proceeding must be immediately given up.

Now, it is for three or four nights and mornings consecu-
tively that this dose of calomel and this purgative draught will
be well borne in the majority of cases; and the better they are
borne, the more likely they are to do good.

But the dose of calomel need not be exactly ten grains,
neither more or less. Finding ten do too little, the next night
I have given twenty. Finding ten do too much, the next night
I have given five: only I would remark, that the dose of

LECT. X.] TREATMENT OF ACUTE RHEUMATISM. 123

calomel must bo a considerable dose. If your patient will not
bear five grains, this method of treatment is not for him, and
the sooner you back out of it the better.

When the full dose of calomel and the purgative draught
have been given for three or four successive nights and suc-
cessive mornings, and have been well borne, and have had the
effect which we desire upon the liver and the abdominal viscera,
it sometimes happens that the same remedies arc thenceforth no
longer needed, and can no longer be borne in any dose. They
have well fulfilled their immediate i:)urpose, and done all they
can do for the ultimate cure. But sometimes they are both
needed, and can be borne a little longer, yet in a smaller dose.
A grain or two of calomel at night and a moderate aperient in
the morning still continue to be required for procuring daily
evacuations.

As this plan of treatment works prosperously day after day
in its immediate effects, so day after day it gives an earnest of
the remedial impression it is exercising upon the whole disease.
It abates the fever, it softens the pulse, it reduces the swelling,
and it lessens the pain. In short, it subdues the vascular
system like a bleeding, and pacifies the nervous system like an
opiate ; and often in the course of a week the acute rheuma-
tism is gone. In three days there is often a signal mitigation
of all the symptoms ; and in a week I have often seen patients,
who have been carried helpless into the hospital, and shrieking
at the least jar or touch or movement of their limbs, risen
from their beds, and walking about the ward quite free from
pain.*

Of this plan, often so striking in its operation, and often so
satisfactory in its results, I have some further remarks to make.
It is called the purgative plan ; yet its purj)ose is achieved by
calomel and purgatives conjointly. The purgatives would not
answer the end without the calomel ; of that I am quite certain :
neither would the calomel answer without the purgatives, unless
it produced of itself ample evacuations from the bowels. It is
probable, in short, that the remedial efficacy of the plan resides
essentially in the calomel : in calomel, however, not as mercury,

* The profession owes tliis practice to Dr. Chambers. Its power and
efficacy are displayed in numerous diseases besides rheumatism, and in their
most perilous emergencies.

124 CLINICAL MEDICINE. [lECT. X.

but as itself — calomel. If the specific effect of mercury — saliva-
tion— arise, it is not only beside our purpose, and against our
wisb, but it begets a serious hindrance to the use of calomel in
sufficient quantity for the end in view. Thus the whole plan
is frustrated. Having begun one plan of treatment, we are
obliged to take up with another. Time is lost, the case is per-
plexed, the disease is prolonged, and the patient perhaps
injured.

This is an accident liable to attend the present plan of treat-
ment. It ivill take place sometimes. It is quite unavoidable.
Men bear no mark that I know of denoting their great or their
small susceptibility to mercury. Of this we must take our
chance, knowing that, be the natural susceptibility what it may,
fevers and inflammations seem counteractive of it to the estent
sometimes of holding it in check, sometimes of suppressing it,
and sometimes of abolishino- it altogether.

The curative effect of calomel then being annexed to its
operation uj^on the abdominal viscera, we should seek by all
means in our power to determine it thither. For this purjDOse
let it neither dwell too long within the bowels, nor be too soon
hurried through them. Ten grains of calomel being given,
should be left ten hours to do its own work alone and undis-
turbed. Its proper work is to impart a peculiar stimulus to
the liver and the intestinal canal, and so to promote a large flow
of bile and various secreted fluids into the bowels. Time is
required for all this ; and the purgative should be delayed until
the excrementitious matter is first formed and accumulated,
and ready to be brought away.

Now, if in the treatment of acute rheumatism you were to
choose one indication and abide by it, and were to trust to one
class of remedies, and to it only, you would find more cases that
admit of a readier cure by the method now described, than by
either of the two former. You would find the aggregate of
morbid actions and sufferings, which constitute the disease,
more surely reached and counteracted, and more quickly
abolished by medicines operating upon the abdominal viscera
only, than by those which influence either the blood-vessels
only, or the nerves only. You would find in calomel and
purgatives a better remedy than either veniesection or in
opium.

LECT. X.] TKEATMKNT OF ACUTE lUlEUMATISM. 120

Tlicrc mio'lit bo occasions and circumstances wlicn ilic blood-
vessels or tlio nerves would oft'er the best channels, and venuj-
section or opium would offer the best means of cure. But the
occasions and circumstances presentino- themselves would rather
lead you to attempt the cure through the abdominal viscera,
and by calomel and purgatives.

Another Avord upon this plan of treatment, and I have done.
It has appeared to me not only to bring this disease to a con-
clusion in a shorter time, but to prei)are the way for a more
rapid convalescence than the other methods.

When the cure of such a disease as acute rheumatism is
largely promoted, or altogether achieved, by calomel and aperi-
ents, it will (I rather think) often turn out upon enquiry, that
the patients prior to their attack were in a state of health which
needed, or would have been none the worse for, a good purging.
Many and many a man have I known, who, having suffered
fever of high vascular action^ and been successfully treated by
remedies addressed day after day exclusively to the bowels, has
recovered rapidly, and thenceforth has enjoyed better health
than he had known for years before. Now, is this the critical
event of the fever, or is it the effect of the remedy? I believe
the latter. I believe that his fever, severe and perilous as it
might be while it lasted, was to him after all a happy event;
inasmuch as he gained by it that medical discipline which he
most needed, and which, but for it, he would not have had the
benefit of.

Seeing then that by the use of calomel and purgatives in the
manner described, patients have so soon thrown off their disease,
and have so soon resumed the conditions of health, do I therefore
finally recommend this last method as the common anchor of
your treatment in acute rheumatism, and allow a place for either
of the other two only when exceptions call for them ? Assuredly
not ! The best single method, or the best single remedy, is not
so good but that it may be made better by the help of other
methods and other remedies.

It is true that I have seen the bleeding plan, the opiate plan,
and the purgative plan each used alone. I have myself used
each alone, and the two latter largely ; and I have told you
what, according to my belief, is their value absolutely and com-
paratively.

126 CLINICAL MEDICINE. [lECT. X.

But tliere is a plan of treating acute rheumatism whicli is
juster and safer, and applicable to more cases, and more
successful than any of tliem. And that plan is a compound of
all three.

This compound method, while it works with all the means
which have been recommended, stops short of what is harsh and
excessive in their use, and yet compasses with more certainty
the successful result.

For I believe, that in the treatment of this disease, and in
the same cases, by the judicious use of opium you may spare
blood, and by the judicious use of bleeding you may spare
opium ; that by calomel and purgatives properly administered,
you may make bleeding and opium less needful, and that by
bleeding and opium discreetly employed you may have less to
be effected by calomel and purgatives.

Hitherto you have seen how, in the management of acute
rheumatism, you may deal with bloodvessels, and with nerves,
and with secreting organs separately, and with what effect.
Presently you will see how and with what effect you may deal
with them simultaneously; and how your different remedies
once set a-foot, and pursuing different paths, meet and end in
one purpose, — and that purpose the cure.

" As many arrows, loosed several Avays,
Fly to one mark."

LECT. XI.] TREATMENT OF ACUTE RHEUMATISM. 12

LECTURE XL

TllEATMENT OP ACUTE RHEUiMATISM CONTINUED. — ITS TREATMENT
ACCOKDING TO MIXED INDICATIONS, AND BY MIXED REMEDIES.

THE BLOOD VESSELS, THE NERVES, AND THE ABDOMINAL

VISCERA, BROUGHT SIMULTANEOUSLY UNDER THE REMEDIAL

IMPRESSIONS OF BLEEDING, AND OPIUM, AND PURGATIVES.

ADVANTAGES OF THIS TREATMENT. OBSERVATIONS ON THE

USE OF COLCHICUM. REPRESENTATIONS OF MEDICAL TREAT-
MENT OFTEN FALLACIOUS FROM BEING TOO FAVOURABLE. — ■
COMMONLY DRAWN FROM GOOD CASES ONLY ; NOT FROM ALL
CASES, GOOD AND BAD. THE GOOD CASES OF ACUTE RHEUMA-
TISM, OR THOSE FAVOURABLE FOR MEDICAL TREATMENT.

THE BAD CASES, OR THOSE UNFAVOURABLE FOR MEDICAL

TREATMENT. NOTICES OF CASES IN WHICH TREATMENT

SUCCEEDS OR FAILS, CONTRARY TO EXPECTATION. NOTICE

OF MEDICINES, WHOSE OPERATION IN THIS DISEASE IS
UNQUESTIONABLY REMEDIAL, YET NOT UNDERSTOOD.

The vascular system, the nervous system, and tlie abdominal
viscera are the channels through which, and venaesection, opium,
and calomel with purgatives, are the means by which, acute
rheumatism is treated and cured. Treated and cured, it may
be, through any one of these channels, and by any one of these
means, singly. But it may be through more than one of these
channels, and bi/ more than one of these means, conjointly. Or
it may be through all of them, and bi/ all of them, together.

The practice which chooses and follows a single indication,
and chooses and trusts to a single remedy, is indeed a plain and
intelligible, but a harsh and subduing, practice. In cases of
ordinary severity, if the entire disease is to be effectually reached
and counteracted through the bloodvessels alone, a single vencc-
section of large amount would be needed, or a venassection of
smaller amount once or twice repeated. If through the nerves
alone, four or five grains of opium would be needed in each

128 CLINICAL MEDICINE. [lECT. XI.

twenty-four hours. If through the abdominal viscera alone, a
large dose of calomel and a draught of senna and salts would be
required night and morning for three or four successive days.

Here is much violence done and felt as the price of success.
Vencosection, single-handed, to do its work successfully, must
strike with the violence that shocks, opium with the violence
that oppresses, calomel and purgatives with the violence that
hurts and irritates. It cannot be otherwise. If one remedy is
to do all, it must be heavily charged and resolutely driven home
to its purpose.

But each remedy may be charged with less force, if one be
made auxiliary to the other. Bloodvessels, and nerves, and
abdominal viscera may be severally spared the shock, the
oppression and the pain, if they are subjected simultaneously to
their several remedies. Thus, in cases of ordinarj^ severity, a
single moderate venaesection instead of several, or instead of one
of large amount ; two grains of opium distributed over twentj^-
four hours instead of four or five grains ; moderate doses of
calomel followed by purgatives instead of very large doses given
and repeated for three or four successive nights and mornings,
comprise a treatment powerful enough, and always safe, and
generally successful, and not painfull}^ felt. Perhaps it would
come pretty near the truth to say, that two-thirds less of blood-
letting, two-thirds less of opium, two-thirds less of calomel and
purgatives, are needed when they are all made confederate for
the cure of acute rheumatism, than when any one of them is
employed alone.

In several cases, however, the proportion of the remedies to
each other would vary. Sometimes more, sometimes less, blood-
letting would be called for, and often none at all. So, too,
more or less opium, and more or less of calomel and ajserients.

I have remarked of the effect of blood-letting in acute rheu-
matism, that it belongs to it rather to render the disease more
curable by other remedies than to cure it itself. Blood-letting,
therefore, properly takes, the lead of other remedies in point of
tiine. For if it be necessary, the whole treatment must tarry,
and other remedies come short of the good of which they are
capable, until it is performed. On the first view, then, of the
patient, the immediate question is — Should he be bled ? and if
so, to what amount? This question it would be foolish and

LECT. XI.] TREATMENT OF ACUTE EIIEUMATISM. 129

dang'crous to pretend to settle any where but in the wards of
the liosi:)ital, and with the very patient before you, and your
finger upon his pulse. "Well, and what then ? Why ! then, if
you judge that there is more force of circulation than calomel
and purgatives operating upon the bowels, aided by the soothing
effects of opium upon the nervous system, will be able to abate,
you may bleed.

This is the best direction I can give. But, be it the best
and wisest that can be given, it must be utterly useless never-
theless, except to those who are or shall be constantly busied
about the sick. For by this direction, whether to bleed or not
to bleed is made to wait upon a judgment which must be formed
uj)on two points. And these two points nothing but the most
constant bedside experience can make sure of. They are these —
the exact force of the circulation, in a particidar instance, to be
ascertained by the pulse ; and the probable power of calomel,
and purgatives, and opium to reduce it, to be estimated by the
ordinary effects of the same remedies.

I do not wish to exaggerate the difficulties of medical
practice ; neither do I wish to conceal them. I am sure you
will never surmoimt them, unless you first feel and acknowledge
them. And some practical experience is needed even for this.

When from the pulse I have considered venajsection neces-
sary to bring down the circulation, the loss of between twelve
and sixteen ounces of blood has generall}^ been enough to answer
the purpose in view ; and the venisection has seldom been
repeated.

The opiimi, and calomel, and purgatives I have been accus-
tomed to give in combination thus : — With the calomel admin-
istered at night, according to its quantity, I have united more
or less of opium. To ten grains of calomel I have added one
grain of opium ; or to five of calomel I have added half a grain,
continuing to give them together in the same proportions, night
after night, as long as they are needed. Then, on each succeed-
ing day, when a large purgation of the bowels has been duly
obtained, I have still given the opium alone, or with saline
draughts, in doses of half or one-third of a grain, every five or
six hours. And thus, with the larger quantity at night, and
the smaller quantities during the day, about two grains of opium
have been commonly taken in the course of twenty- four hours.

9

130 CLINICAL MEDICINE. [lECT. XI.

Here, then, tlie vascular system, and tlie nervous system,
and the abdominal viscera are all at the same time made to feel
sensibly the impression of the remedy, but none of them is
subdued by it. And while blood-letting-, and opium, and calo-
mel with purgatives are all made confederate for the cure of the
disease, none of them is given in excess.

Now, I do not pretend to say, that this is just the measure,
and just the relative proportion in which these several remedies
need always to be emploj^ed for the cure of acute rheumatism.
There are circumstances which would require them to be varied.
But, apart from the patient, they cannot be represented intel-
ligibly. As of venaasection, so of these other remedies, after
the propriety of their use is already understood, the skill of
using them remains to be learnt ; the skill which sees when to
give a little more, and when a little less, often or seldom —
when to bear heavily or lightly on the blood-vessels, when
heavily or lightly on the nerves — and when to obtain larger
purgation of the abdominal viscera. This is the skill which
cures diseases and saves lives. And no man ever had it, who
did not obtain it from his own self- teaching amid the emer-
gencies of actual practice.

There is a remedy much used, and of unquestionable benefit
in the treatment of acute rheumatism, which I must not omit,
to mention. I have not mentioned it sooner, having not been
able to find a place for it among the remedies hitherto spoken
of; for its curative properties are not, like theirs, constantly
annexed to any known operation upon particular organs. But
a remedy may have as just a claim to our confidence from our
bare experience of its doing good (that experience being suffi-
ciently large), as from our perfect insight into its mode of
operation.

Let it be observed, however, that any remedy which, work-
ing in the dark, is nevertheless trusted for its ultimate efiects,
requires to be administered with the greatest care. Even
hecaufiC it works in the dark, therefore, whenever we venture to
give it, the conditions of the malady should always be clearly
those in \\diich it is known to do good; and further, because it
works in the dark, therefore all the possible ways in which it
may do harm should be foreseen and guarded against.

With these remarks, I will proceed to tell you what I know

LECT. XI.] TREATMENT OV ACIU'E KIIBIJMATISM. TU

of tlio use of calehieum in acute vlioumatisin, for It is the
remedy that I allude to.

Colchicum, sing-le-lianded, cannot (I think) be safely trusted
for tlie euro of acute rheumatism in the severer cases, but it
can in the mikler ones; and I have so trusted it: yet I do not
recommend the practice. Colchicum given alone has been slow,
even in these milder cases, of making its curative impression.
Many days have generally elapsed before it has produced any
abatement of swelling and pain, of vascular action and of
fever; and then, not until it has ber/ioi to purge smartly and
fvcn paiufiiUij. JSTow these are hardly satisfactory conditions
upon which to obtain the remedial effects of colchicum. For
to purge by colchicum is to make it act as it does in its first
degree of poisoning.

Findina-, then, that in the milder cases I had no fair chance
of obtaining from it the virtue of a remedy without running
some hazard of it as a poison, it was much too dangerous au
experiment in my eyes to commit the treatment of acute rheu-
matism to it mainly or entirely in the severer cases. For now
it must be pressed nearer and nearer to the verge of poisoning
in order to bring it at all within the capacity of curing.

But in all cases of acute rheiimatism, both mild and severe,
the ])ractice prevails of giving colchicum, not alone, but as an
auxiliary to other remedies. To bleeding and opium and
calomel and purgatives, given in the manner specified, many
would add colchicum. They would prescribe a grain of the
acetous extract, or fifteen or twenty minims of the wine twice
or thrice a day, some considering it to act sedativelj^ and as a
special auxiliary to opium, and some specifically and with the
force of an antidote, as it does in gout.

I, too, use colchicum in acute rheumatism, but not after this
manner. I reserve it for special emergencies; and then I
employ it with a trust and confidence which I have in no other
remedy.

When by vensesection and by opium and calomel with
purgatives, excess of vascular action, and fever and pain and
swelling are abated, yet none of them are entirely abolished,
but all still linger; or when pain and swelling do not subside
at all in proportion to the abatement of vascular action and
fever, which are considerably reduced, then I invoke the aid of

132 CLINICAL MEDICINE. [lECT. XI.

colcliicum, and give twenty or five- and- twenty minims of tlie
wine of the seeds or the root, twice or thrice a day, and I often
find the disease proceed uninterruptedly to its cure.

Again, when by the same ordinary course of treatment
fever, pain, and swelling have been made to cease entirely, and
have suddenly and unexpectedly returned, then I invoke the
aid of colchicum, and give it in the same way; and a few doses
aro commonly enough to dissipate the returning disease, and
restore the conditions of health. This is a pure case of relapse.
The relapse, however, very seldom reaches the severity of the
original attack.

Now on all such emergencies I have been accustomed to
administer the remedy quite alone, uncombined with either
alkali or opiate, so that the benefit which has resulted has been
without question exclusively due to it ; and not only exclusively
due to it, but due to it purely as colchicum in virtue of that
mode of action (whatever it be) which specifically belongs to
it. For the cure has followed suddenly, and not waited for
any intermediate operation of the remedy upon the stomach
and bowels.

Thus I have gone as far as it is safe or profitable for you
that I should attemj)t to go into the treatment of acute rheu-
matism. The rest you must learn by watching the actual
management of cases in the hospital. I can tell you how to
manage a disease, but not how to manage a case. One man may
learn the principles of an art from another's discourse; but he
must learn its practice, not from hearing him talk about it, but
from seeing him in the act of exercising the art itself.

I must not dismiss, however, the treatment of acute rheu-
matism altogether without making one or two additional
remarks, for fear that in time to come you may fancy that I
have not represented the matter quite fairly and honestly.
When some years hence you have gained abundant experience
of this disease for yourselves, I can well imagine you comment-
ing upon me and my practice thus: — "It is all very well
to talk of bleeding, and opiimi, and calomel, and purgatives,
curing acute rheumatism, and setting patients upon their legs
in a week or two; so they will, in many cases. But cases are
frequently occurring, in which neither singly nor conjointly
will they do any thing of the kind."

LECT. XI.] TREATMENT OF ACUTE RHEUMATISM. 1;33

Now this I believe to be the common fault of writers and
lecturers, and of all who in any manner, or any where, under-
take to teach practical medicine, except at the bedside of the
patient, that they give much too favourable a representation of
their subject. And it arises after this manner. In whatever
they say respecting methods of treatment, they proceed in the
meanwhile upon the assumption, that they have always a good
case to deal with, and are always called in at the right time.
Not only do they proceed upon this assumption, but they do it
without saying so.

I can easily understand how, in order to give an intelligible
account of the powers of medicine, it may be necessary to
display it in operation upon states of disease which are most
susceptible of its good impressions. But the teaching which
proceeds upon these terms, whatever other merit it may have,
is not the type of actual practice. For in actual practice there
is no such thing as choosing your own cases — you must take
the good and the bad as they come.

Thus there are cases which present their indications of treat-
ment so clearly and prominently, that medicine is sure of its
aim, and in which all the conditions of time and opportunity
are so favourable that, rightly directed, it cannot fail of success.
These we call, in our peculiar language, good cases; meaning
that they are such as we like to see and like to treat, and have
an interest and hope in, and expect our reward in their speedy
cure.

But there are also cases in which there are no indications
prominent or clear enough to become the special scope of prac-
tice, and in which time and opportunity have been postponed or
lost, so that medicine is never sure of its aim; or, if it should
happen to take the right one, it could hardly expect to reach
it. These we call had cases. We dislike them, and flinch from
them, and can only bring ourselves to treat them as a matter
of duty.

Acute rheumatism has its good and bad cases; its cases,
in which the right treatment is seen clearly and instituted con-
fidentlj^, and pursued in full expectation of success, and success
follows; and its cases, in which the right treatment is dimly
discerned from the first, and the treatment which is adopted
doubtfully, is pursued distrustfully, and ends in failure, or in a

IPA CLINICAL MEDICINE. [lECT. XI.

distant, tardy, and precarious restoration. Of these last I can
scarcely do more than tell you that there arc such cases — I
cannot describe them.

Where the constitution of the patient is habitually cachectic,
and he has no natural health to oppose to the casual incursions
of disease, if that disease he acute rheumatism your treatment
is apt to fail. Again, where the patient is seen late, and
treated late, as in other diseases, so in acute rheumatism the
best medical management is often imable to compensate for loss-
of time, and thus it often fails.

In turning over my records of this disease, I iind that very
few cases came under my observation and treatment during the
first week; that the great majority were admitted into the
hospital during the second, and as much towards the end
of it as the beginning ; that many were admitted in tlie
course of the third, and some not until the fourth week, and
even later.

Again, independent of any fault in the natural constitution
of the patient, or any mischance of time and opportunity in
the application of the remedy, there are certain forms of the
disease in which it bespeaks itself less amenable to medicine.
There is a form of acute rheumatism in which pain, from its
extreme severity, is out of all proportion to the accompanying
fever and vascular action. And there is a form in which fever
and vascidar action with most profuse perspiration and miliary
vesicles are out of all proportion to the pain.

Not only degrees of pain, l)ut its existence, in any degree^
must bo taken upon the testimony of the patient. And I
have seen a few cases in which the complaint of it has been
little or none at all, and the swelling of any joint has been
little or none at all; and yet the fever has been characteristic
of rheumatism in the highest degree, leaving some colour for
speculation whether the disease were not in its essence a fever*
Eoth these foims, that in which the pain exceeds the fever, and
that in which the fever exceeds the pain, arc liable to he-

* The real distinction Letween intianmiation and fever is found Ly
]\I. Andral in the constituents of the Llood. In intianiination its fibrin is
always in excess ; in fever never. Thus acute iheumatism is pre-eminently
an inflammation, and is taken altogether out of the category of fevers. —
Hdiniatologie Pa ihologique.

LIX'T. XI.] TREATMENT OK ACUTE RHEUMATISM. 135

liiigerin<j, and to resist the application of medicine for their
relief.

But there is no such thing as calculating- tlio results of
medical treatment with certaintj-. Success and failure run
contrary to expectation sometimes in every disease, but most of
all in acute rheumatism. Where you would look for failure,
you often meet with success, and vice vend. Of rheumatism it
may be said generally, that it is less within reach of the remedy
in proportion as it is seen and treated at a period more distant
from its commencement. Yet loss of time does not augment
the difficulties of after-treatment, or diminish the probabilities
of its success to the same degree in acute rheumatism as in
other diseases of an inflammatory nature. I have often known
acute rheumatism of the severest kind have the start of the
remedy full ten days or a fortnight, during which nothing
whatever has been done for its relief; and, when at length the
remedy has been applied, it has been cured as easily and
rapidly as I could promise myself that it would have been, had
I taken it in hand ten days or a fortnight sooner.

Surely here is something remarkable enough to make us
stop and think of it for a moment. An inflammation of the
brain, the liver, or the lungs, would not thus wait our pleasure
or our neglect, and be as curable ten days or a fortnight hence
as it is to-day. For inflammation in these organs does not
stand still. It is progressive from stage to stage, and each
succeeding stage carries it further and further away from the
remedy. But it is the very peculiarity of acute rheumatism,
that it does, in a certain sense, stand still. All its actions and
movements are simply as forcible and rapid as possible, yet
does it stand still. All its energy is expended upon one stage,
and there is no apparent jDrogression beyond it. A fortnight
ago there was great heat, and nervous and vascular excitement,
and great pain and swelling of the joints ; and to-day the heat,
and nervous and vascular excitement, and pain and swelling,
are exactly of the same amount as they were at first. There is
no more sign of parts disorganised, or parts destroyed, now than
then. Verily, it seems as if the disease had waited to be
cured all the while. This peculiar pathological condition
may, in fact, be the reason why, after great loss of time, acute
rheumatism is still curable, and often easily and rapidly cured.

136 CLINICAL MEDICINE. [lECT. XI.

But further, as in the treatment of acute rheumatism you
often meet with success, where from present circumstances, and
the analogy of other diseases, you might reasonably expect failure,
so you often meet with failure, where from present circumstances
and the analogy of other diseases, you might reasonably expect
success. As there are frequent cases which suffer no detriment
from delay, but when the suitable remedy comes, though it
come late, are still ready to be cured, so there are cases which
reap no advantage from the earliest and best treatment, or from
the habitual healthiness of the patient, but are still slow and
reluctant to let go the disease. I have seen the joints swelled
and severely painful, the whole surface burning hot, and steam-
ing with perspiration, the vascular system acting with pro-
digious force, and the nervous system wild with suffering for
weeks and weeks together in young and robust constitutions,
and in spite of remedies seasonably employed to fulfd all
rational indications. Here is an assemblage of conditions not
to be found (I suspect) except in rheumatism : the conditions
of acute and chronic disease are united in the same subject ;
actions the most rapid and forcible, and sufferings the most
severe, yet both enduring for a long and indefinite period.
This rheumatism, which is most acute, and at the same time
most chronic, has, at length, worn itself out spontaneously, or
has ceased under the influence of some remedy, whose mode of
operation we know nothing about — colchicum, iodide of potas-
sium, conium, sarsaparilla, cinchona.

I wish I had none of these unexpected issues to tell you of.
They must disappoint your calculations, and disturb your satis-
faction, just when you were, perhaps, beginning to look with
complacency on the happy results of certain straightforward
methods of practice which dealt in simple and powerful means,
and fulfilled plain and intelligible indications, and were said to
do their work, upon the whole, quickly and successfully.

But if I undertake to instruct you out of my little book of
experience, I hold it but honesty to read it straight through.
There is no such thing as turning practical medicine into a
well-told tale. Besides, I doubt whether these exceptional cases
of acute rheumatism are not those which especially deserve
studying, and which promise more than ordinary fruit to tlie
research of the pathologist.

LECT. XI.] TREATMENT OF ACUTE RTTEUMATISM. V\7

There are in acute rheumatism fever, and inflammation, and
pain. And venisection and opium and calomel with purgatives
have abated them, and oftentimes wrought their cure. And it
is wise still to direct our remedies rather in the ways that we
know, than in the ways that we know not.

]5ut probably there is more in this disease than fever, and
inflammation, and pain. And probably there is more in these
remedies than the mere power of softening- the pulse, and
soothing the nerves , and draining the abdominal viscera of
tlieir secretions. As the disease may have an essential element
beyond its sensible actions and sufierings, so the remedies may
have secret operations beyond those which are seen and pal-
pable. And it may be in virtue of those that they cure, and
not of these.

Still we must be content to apportion the remedies accord-
ing to such of their operations as we understand, and leave them
to exercise, as they may^ any others which they possess ; be-
lieving that those, which we do not imderstand (though more
immediately curative), are closely allied with those which we
do, and are ruled and regulated by them.

But, in the mean time, we cannot but wonder that, in the
same conditions of disease, other remedies have proved un-
questionably curative, without any intermediate operations of
the same kind. jS^evertheless, among several remedies, equally
curative in their ultimate effects, but how we know not, it is
best always to choose those, any part of whose action we can
see and control. In whatever bark we put to sea, let us have
a helm to lay hold of, if we can.

Thus much I have thought fit to say of the treatment of
acute rheumatism. And all that I have said applies to it as a
disease consisting of fever and inflammation of the joints,
and of nothing more. And, indeed, acute rheumatism, as far
as the knowledge of former times went, was a fever Avith in-
flammation of the joints, and nothing more. And I heartily
wish that the observation of our own times had added nothing
to it. But I am not lamenting the fruits of clinical and patho-
logical research, or desiring to recede within the limits of a
narrower knowledge. I am only regretting that the things
themselves, which modern physicians have discovered, should
be discoverable, or in other words, should have a real exist-

133 CLINICAL MEDICINE. TleCT. XI.

ciice. For they add so much to the perils of the disease,
and the perplexities of its treatment, that for my own part
I would rather suffer a typhus fever than an acute rheu-
matism.

Now all these perils and perplexities arise from endocarditis
and pericarditis being oftentimes found to form a part of it.
But how to form a part of it ? Why, I believe that the popular
notion regards the disease as it was formerly regarded, as a
fever with inflammation of the joints, and that it views the
endocarditis and pericarditis, whenever they occur, as mere
accidents. But I cannot think so. On the contrary, I must
believe that the rheumatism, of its own nature as a disease,
engenders the endocarditis and pericarditis, otherwise I could
not have deemed it necessary to dwell so long upon its treat-
ment before I came to the treatment of them.

Let me here, in as few words as possible, give you and
myself a little caution against being unawares led to take
various opinions and beliefs in medicine for settled truths,
because the terms in current use among medical men would
imply that they are so. Endocarditis and pericarditis ai'e com-
monly spoken of as incidental to acute rheumatism. But beware
of language, for it is often a great cheat. An incident is some-
thing that possibly may hapjoen — a casualty. But whether
endocarditis and pericarditis arise in two-thirds, or in one-half,
or in not more than one-third, of all the cases of acute rheu-
matism which occur, still to say of them that they are possible
casualties, would lead j)eople greatly to underrate their fre-
quency, and greatlj' to underrate, too, the amount of peril
which belongs to the di sease, entirel}' from their being a part
of it. Besides, to speak of them as incidental, seems to settle
at once that their relation to the rheumatism is of a certain
kind. But who shall say that endocarditis and pericarditis are
not equally essential to it with inflammation of the joints, and
that both are not equally derived from the attendant fever ?
Or who shall say that the arthritic inflammation and the car-
diac inflammation, and the fever itself, with its profuse and
sour-smelling perspirations, and the urine, loaded with lithates
and red colouring matter, do not all sjDring from some noxious
principle formed in, or finding its way into, the blood, this last
containing, in truth, the essence of the disease?

LECT. XI.] TEEATMEN'J' OF ACUTE KIIEUMATISIM. 139

Organic clieiuistry alone can settle the point, and proLaLly
Avill settle it some time.

In the mean while we are called to treat acute rheumatism,
and all that helongs to it, upon such knowledge as we possess.
J]ut in so doing, let us not deceive ourselves into believing
lliat \\c know more than we do, merely because we choose to
adopt terms which seem to imply great knowledge. " Inci-
dental" and "essential" are words which have a show of
v.isdom. Eut we are not sure that the johenomena of the
disease to which they arc ai)plicd can, with propriety, bear to
l;e £0 designated. The words vouch for more than at present
is actually known.

140 CLINICAL MEDICINE. [leCT. XII.

LECTURE XII.

PREVENTIVE TREATMENT OF RHEL'MATIC ENDOCARDITIS AND

PERICARDITIS CONSIDERED. IN THE MANAGEMENT OE ACUTE

RHEUMATISM CAN ANY REMEDY BE USED AS SPECIALLY PRE-
VENTIVE OF, OR ANY RE:\IEDY BE AVOIDED AS SPECIALLY CON-
DUCIVE TO, ENDOCARDITIS AND PERICARDITIS ? IS OPIUM

PREVENTIVE ? IS ^■EN,^^SECTION CONDUCIVE ? IN WHAT

THEIR PREVENTIVE TREATMENT REALLY CONSISTS. THEIR

ACTUAL TREATMENT. IT SHOULD BEGIN WITH THE EARLIEST

NOTICES OF THEIR EXISTENCE. WHAT THESE ARE IN THEIR

SEVERAL VARIETIES. WHY, IN ACUTE RHEUMATISM, THE

HEART, BEING INFLAMED, NEEDS A SPECIAL TREATMENT,

WHILE THE JOINTS BEING INFLAMED NEED IT NOT. THE

TREATMENT OF THE HEART, HOWEVER, BY THE SAME REME-
DIES AS THE GENERAL DISEASE. BUT THIS TREATMENT MADE

SPECIAL BY THOSE REMEDIES BEINCt USED WITH A DIFFERENT

FORCE, AND IN NEW DIRECTIONS. BLEEDING AND OPITTM

USED THUS. THE CONSIDERATION OF THE USES OF MERCURY

POSTPONED.

Whenever endocarditis or pericarditis has made a part of
acute rheumatism, it has rarely been present from its com-
mencement, but has in almost every case been superadded to
it during its progress. There have been fever and inflamma-
tion of the joints for an uncertain period, before the affection
of the heart has arisen.

I say, in almost every case. For I have known exceptions :
I have seen cases in which the inflammation of the heart has
been declared as soon as the inflammation of the joints: even
as soon as the disease could be called rhcimiatism, endocarditis
or pericarditis has been already a part of it. And I have
seen a few cases (but very few) in which the inflammation
of the heart has seemed to precede the inflammation of the
joints. There has been fever, and with it palpitation and
prajcordial pain. Thus for the disease has been a puzzle. In

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 141

a day or two the joints have become inflamed, and shown the
disease to he rlicnmatism ; and the endocardial murmur has
I)ccn added to the palpitation and to the pra)cordial pain, and
shown the sure existence of endocarditis from the beginning.

But bej^ond all question in the vast majorit}^ of cases, where
endocarditis or pericarditis has eventually apjjcared, the rheu-
matism has begun, and proceeded for a time without any
symptoms immediately referable to the heart.

Now, if experience has found any treatment which is pre-
ventive of endocarditis or pericarditis, this is the time for carry-
ing it into effect — the time of the heart's immunity, which
would thus become the most eventful and most important
period of the disease.

AYhether there be any special safeguards or modes of rescue ,
that can then be put in force, I will consider presently. But,
alas ! I must first tell jou that the time is too often past before
the disease is brought under our care and treatment. The
poor are the most frequent subjects of acute rheumatism ; and
the following record will show in how many the precious op]3or-
timity of preventive treatment was already lost before they
reached the hospital.

Out of the 63 cases of rheumatic endocarditis the endocardial
murmur was found to exist upon the patient's admission in 27;
that is, in 3 cases out of 7. And out of the 18 cases of rheu-
matic pericarditis the exocardial murmur wj^s found to exist
upon the patient's admission in 9 ; that is, in one half. Further,
out of the remaining 45 cases of one or other of these diseases,
although upon admission the sure auscultatory signs were pre-
sent in none, yet in many there were pra^cordial pains, or
palpitation, or irregular pulse, or catching of the breath ; and
it was often part of their history, that they had existed some
time previously. But where these were, there the endocardial
or the exocardial murmur was sure to follow, thus denotino-
infallibly the nature of the disease, and at the same time plainh"
interpreting the meaning of the symptoms which preceded
them, and showing that they were derived from the same
endocarditis or pericarditis with themselves.

I have already shown that, from the condition in life of
those who are most apt to suffer it, a considerable period is
wont to elapse after the acute rheumatism has begun, before it

142 CLINICAL MEDICINE. [lECT. XII.

is subjected to medical care; a loss of time and opportunity
often un25ropitious to the treatment of tlie entire disease, and
(it now appears) still more disastrous in prohibiting the use of
all possible means to "[prevent those affections of the heart which
impart to it its most formidable character.

But still acute rheumatism is presented often enough to our
observation unaccompanied by these affections of the heart to
allow the foir trial of means for preventing them, if any such
there be. Xow, I believe there are means which answer this
among other purposes ; but no ^<pecial means to answer tlm
special purpose.

I am aware that the treatment of acute rheumatism by large
and often-repeated doses of opium (much larger doses and
oftener repeated than I have been accustomed to employ) has
obtained the high recommendation of being a safeguard to the
heart. Nothing, however^ is more difficult than to reach satis-
factory conclusions upon points of this kind. Only consider
what a vast number of comparative trials is needed to prove
that one remedy has greater power than another to mitigate or
arrest even actiiallij existing symptoms ; and then think of the
infinitely greater number of such trials required to show one
remedy more efficacious than another in preventing certain
symptoms, which possibly might have been, but which never
actually appeared.

On the other hand, there is a remedy which I have heard
emphatically denounced as inadmissible in the treatment of
acute rheumatism, because it favours the metastasis, or the
extension of the disease from the joints to the heart : this
remedy is vensesection. And if, in my belief, the imputation
Avere true, I ought to warn you seriously against its use. For,
practicallj', preventive caution and preventive treatment arc
the same thing.

But I believe that the omission of venocsection might bo
denounced with as much justice as the practice of it for increas-
ing the liability of the heart to suffer in the progress of acute
rheumatism. The truth is, venocsection can neither be com-
mended nor discommended ahsohdehj on any such grounds. It
guards the heart, or it exposes the heart, according as it is or is
not employed in proper season and in proper measure.

All that has been said of the rig-ht and wroncr use of venoc-

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 143

section in tlio management of the general disease migTit now
1)0 repeated, with the particular aim of preserving the heart
imtouchcd. Omit vemcscction altogether, where the patient is
young and vigorous, and where pains, and swelling, and fever,
and vascular action, and all that characterises inflammation,
are in excess, and you fling away the remedy of greatest power
hoth for curing what is, and for prccoduifj what may be. All
other remedies put together cannot compensate the loss of this,
whether for cure or for prevention, Nay, all other remedies,
for want of the preliminary impression which this alone can
exercise upon the blood-vessels, will, each of them, fail of their
proper efficacy, and be almost as if they had not been employed
at all. Thus, the inflammation is both immitigated in the
parts where it is, and unrestrained from going wherever else it
will ; and so it goes, whither it naturally tends, to the heart.
All this I have seen, and know.

Or employ venscsection recklessly and beyond the necessity
of the case, and in great excess, and you may cure the rheu-
matism at once, or you may so abate the force of all its symp-
toms as in a manner to suspend it. But, whether you cure it
or suspend it, it must be by a shock. And, if you do but sus-
pend it, as the constitution recovers from its shock, and as the
disease returns afresh, there is a perilous chance that it may
not be exactly what it was before, but something worse. Before
the unsparing vena^section it was a fever with inflammation of
the joints only ; in lighting up anew after the venajsection, it
may be a fever with inflammation of the heart as well as of the
joints. This also I have seen.

There is a lesson which we are apt to learn slowly, but
which all of us come to learn at last. It is this — that while
present pain and present peril call loudest for relief and rescue,
still in relieving and rescuing, the ultimate well-being of the
patient must not be disregarded altogether.

To compare great things with small, it is not only in the art
of war that an imprudent victory has been the beginning of
many disasters.

Whatever be upon the whole the best treatment of acute
rheumatism, the same may be considered the best safeguard
against extraordinary perils belonging to conditions which may
arise in the course of its progress. While it promotes the cure,

144 CLINICAL MEDICINE. [lECT. XII.

it tends to restrict the disease to the parts whicli it at present
occupies until the cure is complete. And whatever be the
"worst treatment of acute rheumatism, the same is the surest
exposure to those perils against which the best treatment is a
safeguard. While it delays the cure, it allows the disease time
to travel beyond the parts which it at present occupies to others,
which in its own nature it is liable to seize upon.

But suppose the heart to be actuaUy attacked with inflam-
mation, what is to be done ? I am sure I cannot tell you
summarily, and in the gross, what is to be done. I must first
bring together some circumstances and conditions of actual
practice, and place you (as it were) in the midst of them, and
then teach you how to act when I have taught you how to
estimate the emergency.

Take a case which you have watched and treated day after
day; a case in which day after day you have examined and
listened to the chest, fearing and guarding against surprise, and
have felt all possible confidence that hitherto the heart is free.
In such a case pain arises, distinct and sudden pain in or near
the praccordial region ; or the heart suddenly begins to beat
with excessive impulse ; or the heart, as if struck with weak-
ness, suddenly begins to flutter and act irregularly. But withal
your ear detects neither bellows-murmur, nor sound of attrition.
What then are you to think of the disease, and what to do ?
You are to conclude that inflammation is begun in the heart, and
you are to take measures to subdue it without a moment's delay.

Pain in the heart ; excessive impulse of the heart ; irregular
action of the heart ; any one of these, or any two, or all of
them together, coming on in the course of acute rheumatism,
make inflammation of the heart so nearly certain, that it would
be folly to suspend the remedy by waiting for more certainty,
and so running the hazard of having a more advanced and less
tractable disease to deal with.

But what is it you would wait for to make the fact of
inflammation certain 'f The auscultatory signs, perhaps. And
I may be told that I cannot be absolutely sure without them.
But there are cases in which it is your duty to be practicaUij
sure, before you are sure by the card ; and this is one of them.
You would not sacrifice men's lives to the vanity of diagnosis.
The auscultatory signs, when they come, will only serve to

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTION'S. 140

localise the disease. Its nature is plain enougli already; and
wc treat /Y.s natiive, and not iU sent.

Tlic truth is, if the heart be to suffer inflammation, it is a
most happy circumstance, that tlie first notice of it should be
thus declared. Happy, however, only, if such notice be under-
stood and acted upon.

Eut do not imagine that I wish to disparage auscultatory
signs, because I here so strongly insist, that you should trust to
other signs, and proceed without them. Presently you will sec
liow entirely I confide in them.

Take another case of rheumatism, in which you have been
daily upon the watch for the least sign of evil befalling the
lieart, and hitherto have found none: no pain, no excess of
impulse, no irregular action. In such a case, when you least
expect it, you may hear somefhing unusual in the heart. If.
may be its systolic sound prolonged in an undue degree, or a
little harsh, and nothing more. Yet this, if it be really so,
even this alone is enough to call for instant measures to subdue
inflammation of the heart. For it is almost certain that by
to-morrow, this sound, a little more prolonged, and a little
liarsher than natural, will become a genuine bellows-murmur,
and declare the sure existence of endocarditis.

Indeed I am not over-refining in this matter, and those who
are in the habit of attending my visits to the wards know that
I am not. They know, too, that I have taken some pains not
to be deceived about it. For it is hard to judge and decide
truly upon our smaller perceptions; upon things which reach
the senses, indeed, but strike them only feebly and faintly.
Yet, when these smaller things have such important meanings
as they have here, judge we must, and decide we must, using
idl caution to avoid error.

When, therefore, in acute rheumatism my ear has told me
of a more prolonged and somewhat harsher sound of the heart
than natural, I have not been content until I have found
another ear (some well-instructed and experienced one) to bear
testimony to the same fact, and give me assurance that my own
did not err. And then I have ventured to play the prophet,
and to foretell that, by the next day, this sound would be a
bellows- murmur, and inflammation of the endocardium would
be unquestionable. To me it has been unquestionable already,

10

146 CLINICAL MEDICINE. [lECT. XII.

and so, not waiting for to-morrow, I have begun its treatment
at once.

Take another case of rheumatism, in which neither proecor-
dial 2)ain nor excess of impulse nor irreguhir action have hitherto
drawn attention to the heart, nor do they now. But now your
oar may begin to admonish you of something belonging to the
heart, which was not there the last time you listened: a sound
which is no modification of what is found in health , but is
entirely new, and unnatural. This sound may be as yet audible
in so small a space of the proocordial region, that, of several who
have been carefully listening to the patient's chest during the
last half hour, one only has happened to light upon it. Yet it is
so sure and certain a reality, that no sooner is attention pointed
to the spot, than all can hear it, and all have no doubt of it. The
sound is an indefinite sound still; each person who hears it
likens it to something different. It is not such as can fix
disease either upon the endocardium or the pericardium. But
coming on in the course of acute rheumatism, it must be taken
for an announcement that all is not right in the heart, that it
has beffun to suffer after the manner to which acute rheumatism
renders it obnoxious, and that it is already in a state of inflam-
mation. Therefore the remedy must no longer tarry. Ere a
day is gone, this indefinite sound will be changed into an endo-
cardial or exocardial murmur.

Take yet another case in which, from the absence of all
symptoms referable to the heart, you believe it to be hitherto
imhurt. You listened perhaps a few hours ago, and still found
nothing to excite suspicion. And now listening again you hear
the endocardial, or you hear the exocardial, murmur completely
formed. These sounds, being the concomitants of acute rheu-
matism, announce at once inflammation of the heart, and fix
its seat either in the membrane which lines it within, or the
membrane which invests it without. Here nothing is wanting
to the instant and complete disclosure of the disease; and
nothing should be wanting to the immediate and efiicient
treatment of it.

These are the ways in which I have seen endocarditis or
pericarditis begin, when I have witnessed their beginning.
Things different in kind, a jDain, an impulse, or a sound ; things
great or small, palpable, or hardly discernible, and never discerned

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 147

but by the practised sense, have given the first authentic notice
of these awful diseases. Therefore the eye, the car, and every
sense and faculty, which can convey intelligence of what goes on
within a man should be kept upon the watch for these things.

I have learnt the good of knowing, and the evil of not
knowing, their import. And truly do I wish that I could live
a few past years again, and carry back with me my present
experience for the sake of treating again some cases of rheu-
matic endocarditis and pericarditis, and of treating them better.
I fancy I could now save some hearts from permanent injury
which then I did not save.

If I had to treat certain cases which I have seen, Avhen
there was complaint of pain in or about the praccordial region,
I should not speculate about its possibly being an intercostal
pain, and so delay for a while (as I have) the treatment of the
real disease. When there was excessive impulse of the heart I
should not wait, moreover, for a certain unnatural sound to tell
me what it meant ; and when there was an unnatural sound of
an indefinite kind, I should not make treatment tarry until this
sound became an unquestionable bellows-murmur, or sound of
attrition. Heretofore, I confess, some such cases had not the best
treatment at my hands, because they had not the earliest. And
they had not the earliest, because I did not clearly discern the
earliest notices of the disease; and so it had the startof my remedy.

These confessions I freely make, that you may profit by
them. I cannot carry my experience backward, but you may
carry it forward. And it is in the hope of some practical good
to come from it, that I have thus analj'-sed and exposed it.

But you must not from my own confessions take occasion
to blame me. The whole subject was new to clinical research.
And, long after much general acquaintance with it had been
obtained, those many smaller pieces of knowledge, bj^ which
especially practice is perfected, were yet to be picked up and
examined, and rated at their just value. Do not blame me,
that I did not find them, and take them, and turn them to all
their best uses in a moment.

Well ! then, now you know the signs, which in acute
rheumatism are fit to raise alarm, and to proclaim that all is not
well with the heart. And whenever any of these appear,
whether auscultatory or non- auscultatory, many or few, great

148 CLINICAL MEDICINE. [lECT. XII.

or small, whether enough to indicate the disease, but not to
determine its exact seat, or enough both to declare it to be
inflammation, and to fix its seat in the endocardium or pericar-
dium, or in both simultaneously, your treatment must at once
be directed to the heart. But what is that treatment to be ?

It has been already said, that in acute rheumatism the treat-
ment of the joints may be safely merged in the treatment of the
general disease. And why so ? Because in acute rheumatism
inflammation of the joints, be it ever so severe, is not wont to
terminate in their disorganisation. The fibrous, cellnlar, and
synovial structures, which compose them, will abide in a state
of inflammation for weeks, and sufier the matter which inflam-
mation efi'uses (fibrin and albumen) to be deposited within
them and about them, and yet in the end recover their perfect
soundness and integrity.

But in acute rheumatism the treatment of the heart cannot
be safely merged in the treatment of the general disease. And
why not ? Because inflammation of the heart tends to a
destructive disorganisation. Every day that it is allowed to
abide and continue its progress, the heart sustains more and
more injury from morbid matter deposited upon it or within it,
and its functions are hindered and baffled, and at last abolished ;
and these functions are vital.

When the question is of the joints, it might be laid down
as a maxim of practice, to treat the rheumatism (or the general
disease), and let the joints take care of themselves. But when
the question is of the heart, the maxim might be stated con-
versely; to treat the heart, and let the rheumatism take care of
itself. For inflammation of the heart, whether endocarditis or
T>ericarditis, being the accompaniment of acute rheumatism, is
to be managed by the same methods and remedies as it would
be, were it alone and idiopathic. And these methods and remedies
are such as might not be employed at all, or certainly not to
the same extent, in a rheumatism attended only by inflamma-
tion of the joints.

Now I admonish you that I am going to enter into bedside
details. For I can teach you nothing unless I do, and you can
leaim nothing unless you attend to them. Bloodletting, and
mercury, and opium, are your remedies for these diseases of
the heart. And so they are for acute rheumatism, irrespective

Ll-XT. XIl] TKIvVTMENT OF THF. CVRDIAC AFFECTIOXS. 149

of inflauiniatiou of the heart. And so they arc for twenty
diseases besides. Bat little practical instruction is conveyed
siinply by announcing- the fact. For in each of the twenty
diseases, nay, in each case of any one of thoin, they may need
to be employed in different modes and measures. Thus they
are only comiltloaalli/ curativ'c after all. But is not this almost
us much as can be said of the application of any remedy to any
disease P Conditions mix themselves with all medical practice.
To know the disease and to know the rig-ht remedy, are only
iirst steps towards the right treatment. The success, and even
the safety, of practice come from knowing things which lie far
beyond. Stop here, and you will soon find it much easier to
kill a man with the right remedy than to cure him.

Bleeding, mercury, opium, the very remedies j^ou used in
acute rheumatism, are (I say) still your main reliance, when
inflammation attacks the heart; but bleeding in different modes
and measures, mercury directed to a totally different purpose,
and opium given with more than one single intention.

As soon as inflammation is known or suspected to have
reached the heart, mercurj^ must bo given without delay. Or
should mercury be already in use, as a remedy for acute rheu-
matism, with the intent of obtainino; larg'e evacuations from the
bowels, it must at once have a new direction given to it. The
irritation it has produced within the abdomen must by all
means be pacified, and its constitutional impression must now
alone be thought of, — that impression, of which salivation is the
best evidence, of which (as far as we know) it alone, of all
remedial substances, is projjerly and exclusively capable, and
which, under favourable circumstances, is largely counteractive
of inflammation.

But, inasmuch as that impression of mercury, or salivation,
which is the best evidence of it, cannot be commanded within
any given time, you must be content to administer it in the
manner calculated for this purpose, and wait the event. For
no judgment can be formed of its curative eflect upon the disease
until salivation arrives. And it may arrive in a day or two, or
not until after several days, or after a week, or after several
weeks, or it may not arrive at all.

You must give mercury, then, and wait until salivation
come to tell you what it has done for the disease, or until it is

150 CLINICAL MEDICINE. [lECT. XII.

fair to conclude there will be no salivation. And it does, I
confess, require strong confidence in this great remedy, thus to
give it, and thus to wait for its ultimate effect, when in the mean
time it displays no proximate or intermediate effect as an earnest
of its curative operation.

But as in actual practice, so in description, we must now
leave this remedy for a while, sujjposing it to be duly given
and duly in operation towards its ultimate effect, and return to
it again, when we have considered the uses of the other remedies.

Now the other remedies, while they have their ultimate
effect, which is to be seen and judged of in the end, have their
immediate effects, which are to be seen and judged of from day
to day, and from hour to hour. Their ultimate effect is to cure
the inflammation. Their immediate effects are to abate pain
and anguish, and dyspnoea, and palpitation ; to quiet the nervous
system, to produce sleep, to moderate fever.

"With respect to vensesection, if in acute rheumatism any of
those symptoms referable to the heart are present, which have
been already mentioned, auscultatory or non-auscultatory, and
especially if they have arisen under your own observation, or,
though not under your own observation, if they be now present,
and you have reason to believe that they have recently arisen,
then, should the pulse be found to have even a notable degree
of that hardness which is deemed inflammatory, blood must be
taken from the arm. Should there be any doubt about venae-
section, any misgiving whether the inflammatory hardness of
the pulse is quite enough to require it, let it be employed never-
theless. There is greater hazard in omitting it wrongfully than
in practising it wrongfully.

But with the same amount of vascular action evidenced by
the state of the pulse, in a case of mere rheumatism, in which
the heart was not affected, vensesection would be neither neces-
sary nor proper.

Again, if in acute rheumatism, with symptoms referable to the
heart and those recently declared, fever and vascular action run
very high, and there be extreme fulness and hardness of the
pulse, a copious venacsection should be practised. And the same
should be repeated, were the hardness and fulness of the pulse
found not to yield. And repeated again and again, until the
hardness and fulness of the pulse were much abated.

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 151

AVith all this fever and inflammatory action, and all this
hardness and fulness of the pulse, had the case been one of mere
rheumatism, and the heart unaffected, venacsection would have
been properly employed, indeed once or even twice, but it would
not have been carried further for reasons formerly assigned.
Now, however, more danger is to be feared from the progress
of inflammation in the heart, than from any shock imparted to
the nervous system by loss of blood.

But though the disease be inflammation, and the organ
inflamed be a vital organ, even the heart, bleeding must have a
limit ; for bleeding cannot alone be trusted to cure the disease.
Mercury must become its auxiliary. And if for no other reason
than to obtain from mercury a fuller curative operation, bleeding-
must have a limit.

Looking, as I do, mainly to mercury to save life, or to save
the organ, I am constantly ca^-eful in the management of every
case to do every thing to aid, and nothing to hinder, its curative
operation. Especially in the use of venoesection, I bear this in
mind ; for sure I am that loss of blood can both aid and hinder
it according to its amount.

In men of florid aspect and full blood-vessels, though bleeding
has not been needed for its own sake, yet has it oftentimes been
moderately used for expediting the sensible eflects of mercury.
And the sensible effects thus induced have been at the same
time curative. But, if the body be first made exsanguine by
the lancet, you may gain the sensible effects of mercury, and lose
the curative ; for the two do not of necessity go together.

As mercury can be less trusted for its antiphlogistic power
in those who either naturally or from previous disorder are pale
and anaemic, so in the robust and sanguineous if you would have
mercury exercise what power it has for the control of inflam-
mation, you must beware of malcing these what the others are.
You must hold your hand from excessive venacsection. In in-
flammation of the heart you must not first change a fine ruddy
countenance into the aspect of a chlorotic girl, and then leave
mercury to complete the cure without anxiety or distrust of the
event.

EecoUect, then, that in rheumatic inflammation of the heart,
'whether it be endocarditis or pericarditis, bloodletting by venae-
section is to be little in one case, and much in another, according

152 CLINICAL MEDICINE. [lECT.

XII.

to tlie present force of vascular action throughout the body ;
little or much respective to its own proper benefit as a reined}' ;
and little or much respective to its secondary uses in procuring-
the more effective operation of mercury. And, recollect, more-
over, the cautionary admonition applicable alike to the manage-
ment of this and of all diseases in which a large share of the
cure is confided to mercury; recollect, not to lessen or to lose
its curative operation, either by bleeding too little or bleeding
too much ; for plethora and anaemia are alike obstructive of it.

But there are other modes and means of bloodletting
besides vena}section. There is cuj^ping, and there are leeches.

Now in rheumatic inflaiumation of the heart, cupping or
leeches, or both, may be needed as auxiliary to vena:section ;.
or, exclusive of vena?section, they alone may be needed and
trusted for taking as much blood as the nature of the case
requires.

As it often happens to other orgfjns when they are inflamed,
fio also to the heart, that, when general vascular action has run
high and vena^section has been employed to reduce it, and hun
I'cduced it effectually, the local symptoms will remain altogether,
or almost unmitigated. Thus jjain and palpitation of the heart,
and unnatural sounds, often abide in the same degree, or nearly
so, after vena?section as before it ; and then cupping or leeches
come in as effective auxiliaries, and the local bleeding often
makes at once an ap2)reciable impression upon what the general
bleeding has not touched.

Again, as in other parts of the body, so in the heart, it is no
^mcommon thing for inflammation to begin andpi^ocecd onwards
to destructive disorganisation '^fvY/zo;;;? being felt as an inflainniatio)!.
])y the constitution at large. It imparts no special hardness to
the pulse, and no extraordinary force to the circulation, yet it is
working its own injurious changes locally; palpitation, or pain,
or irregular action, or unnatural sounds, declare as much. Here
all that bloodletting can compass for the relief of the disease
and its symptoms will be attained by cupping, or by leeches alone.

Now there is a choice between cupping and leeches. One
may be a more appropriate remedy' than the other in a particular
case ; and yet I dare hardly trust myself, apart from the patient,
to jioint out what it is that should determine you to prefer one
to the other.

LEC'J\ XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 153

So dexterous are those wlio are well practised in tlie art of
cnpjiing that they can make their glasses draw a given quantity
of blood in almost as short a time as the lancet ; whereas leeches
are long at work in taking away the quantity you desire. There-
fore, upon the principle of requiring in the remedy a force and
rate of operation proportionate to the force and rate of the
disease, I should say that when the pain or anguish, or by what-
ever name you call the distress immediately referable to the
heart, begins suddenly, is at once felt severely, and augments
rapidly, then cupping is the remedy ; but that, when it comes
on by little and little, and increases slowly, and has not yet
reached a great amount, then leeches are the remedy. But leeches
are often needed as auxiliary to cupj)ing, just as cupping is to
ventcsection.

There is another thing worth mentioning as to the use of
these remedies. When I have employed cupping in inflamma-
tion of the heart, I have been accustomed to have the glasses
applied between the left scapula and the vertebral column.
Applied upon the pra^cordial region, they have seemed to me to
cause peculiar distress, and to be not without the hazard of
doing mischief and violence to the heart in its present condition :
for recollect that noic a slight percussion upon the cartilages of
the ribs, or any degree of pressure which shall carr}^ them ever
so little downwards towards the heart, will often occasion pain.
Besides, blood taken from between the scapula and the
spine produces all the relief to the heart which could be
expected.

But we must come nearer yet to the bedside of the patient,
and look still more closely into the immediate efl'ect of blood-
letting in inflammation of the heart. Its effect, day by day, is
the earnest of its ultimate effect. The sensible impression of
each venaesection, or of each cupping, or of each application of
leeches, is a measure of the good they are doing, and of the trust
to be reposed in them as remedies. But what is this effect which
is to be looked for day b}^ day ?

In inflammation of the lungs or pleura, bloodletthig shows
its favourable impression by setting free the respiration and
diminishing pain. In inflammation of the brain, by abating
delirium, or coma or spasm, by restoring clearness to the senses,
and intelligence to the mind ; in inflammation of the perito-

154 CLINICAL MEDICINE. [lECT. XU.

neum, by softening the tense abdomen, and making it more
patient of pressure. And if the heart be inflamed either within
or without, any of the several modes of bloodletting will denote
itself to be exercising a curative power on the disease, when it
moderates pain, or when it moderates excessive impulse, or when
it renders its beats regular again, which were irregular before.
Thus it is in the sensations and functions of the heart as of other
organs, that we see the benefit which bloodletting is doing, or is
ultimately to do, towards the cure of its inflammation.

Next as to the use of opium. It indeed is needed now that
the heart is inflamed, to calm the nervous system, and to abate
pain, as it was needed before ; and, moreover, it is needed for
another purpose, viz. to give efiect to the operation of mercury
in one mode at least of administering it.

If in aiming to produce salivation you give calomel inter-
nally, you must restrain it from running ofi" by the bowels :
and this can only be done by opium. Opium must be combined
with every dose of calomel, and the quantity of each must be
proportioned to the other. Thus, perhaps, we shall generally
find ourselves compelled to give more opium for the purpose of
keeping the bowels patient under the stimulus of calomel, than
we should give merely to soothe the nervous system under the
general irritation of the disease. But, as the remedial opera-
tion of mercury is not now under consideration, it is imneces-
sary to say more at present of opium as its adjunct and
auxiliary.

Beside, however, these its common uses of calming the
nervous system and abating pain and aiding the effect of
mercury, opium has its extraordinary uses for extraordinary
emergencies. In endocarditis and pericarditis, not always, but
most commonly, pain is present ; pain of the heart varjung in
amount, and upon the whole abiding, yet allowing remissions
and abatements. But whether this customary pain be present
or no, a sudden agony will sometimes seize the heart, and at
once the patient will feel and look as if he had received his
death-blow. It is like a spasm of the heart. It is no other
than a paroxysm of angina pectoris. This terrible seizure
attends pericarditis more frequently than endocarditis, and
where it has once occurred, it is apt to occur again. Its only
remedy, as far as I know, is a large dose of opium. Opium is

LECT. XII.] TREATMENT OF THE CARDIAC AFFECTIONS. 155

the only means of rescue during the agony, and the only safe-
"juard ao:ainst its return.

Thus it is with opium as it is with bleeding. Day by day
it makes its sensible impression both upon the constitution at
large, and upon the diseased organ. It is pre-eminently
sedative and anodyne and antispasmodic. And so day by day
it is curative in a certain measure, and gives assurance that it
is contributing in the mean time to the ultimate cure.

Well, then, while we look to feelings and functions, both
constitutional and local, and gather notices from them that our
remedies are working beneficially towards their end, have not
the auscultatory signs some intimations of the like import to
give us ? Having gained great information from them respect-
ing the nature and seat of the disease within the heart, and the
period of its commencement, we are disposed to look to them
to tell us of its decline and reparation. And no doubt they do
tell us a great deal ultimately. They give us all the knowledge
that can be gained of the condition to which the heart reverts
at last. But in the mean time, are not changes to be sought
for in the auscultatory signs day by day as bleeding after
bleeding, or remedy after remedy (be it what it may) is
employed, changes which shall show the curative effect of the
treatment now in progress ?

Experience says that changes in the auscultatory signs do
not occur after this manner ; and the nature of the thing shows
that they cannot.

By vensesection or other modes of bleeding, by a blister or
by a dose of opium, pain, anguish, or palpitation or irregular
action of the heart, are subdued or pacified, or made more
tolerable ; and the same symptoms returning, are again brought
under by the same remedies. But in the mean time, the mur-
murs, endocardial or exocardial, which have been present from
the beginning, do not come and go, and rise and fall. "When
pain or anguish, or palpitation, or irregular action of the heart,
is the greatest, the unnatural sounds are not the loudest. When
those are the least, these do not become faint or inaudible. So
says experience.

Now only consider how different in their very nature are
those symptoms and these auscultatory signs, and wherein that
difference consists, and you will presently see how it comes to

156 CLINICAL MEDICINE. [lECT. XII.

ITdss that they cannot both be brought under equal degrees of
abatement and control by the same remedies.

Pain, anguish, pali^itation and irregular action, are things
purely vital. They are the sensibilities and fvinctions of the
organ exalted and hurried, and baffled by the present stimulus
of inflammation. And so far as the remedy can subdue it
partially or entirely, temporarily or permanently, they are
made to subside or to cease for a while, or altogether. But the
endocardial and the exocardial murmurs are annexed to purely
mechanical conditions, and proceed from new substances formed
within and without the heart. And as long as these substances
I'emain, whether the heart move forcibly or feebly, rhythmically
or irregularly, with pain or without pain, it cannot move with-
out the accompaniment of these sounds.

It is true that these substances are formed by the blood-
vessels engaged in the inflammation. But the i)roducts of the
inflammation remain for a time after the actuating principle
and vital movements of the disease have ceased. And as long
as they remain they have mechanical effects according to their
kind, their seat, and their degree. As long as lymph abides
upon the internal lining or external covering of the heart,
though inflammation have entirel}' ceased, unnatural sounds
must result. As long as the blood has a thickened valve, or an
unequal surface of the endocardium to pass over, it must pass
with a whiz. As long as the folds of the pericardium, being-
still free to move, encounter ruggedness and inequality, the}^
must move with a grating noise.

Learn, then, to read aright the meaning of these two orders
of symptoms referable to the heart, — the vital and the mechan-
ical. Beware, especially, when the question is concerning the
effect of remedies upon the disease, of mixing or confusing the
iatelligence which each has now to give. The vital symptoms,
when they cease, denote that the inflammation has come to an
end. The mechanical symptoms, when they yet continue,
denote that the effects of the inflammation remain. The two
do not speak a contradictory language, but they s^jeak of
difl'erent thina'S.

LECr. XIII.] MERCURY TN IJ^IM. VMMAT[0>f. V)7

LECTURE XIII.

THE GENERAT> QUESTION CONSIDERED OF MEllCUllY BEING A

REMEDY FOR INFLAMMATION. CONDITIONS FAVOURING ITS

REAIEDIAL OPERATION. THESE FOUND IN THE NATURE OF

THE INFLAMMATION, IN THE FART IT OCCUPIES, AND IN THE
CONSTITUTION OF THE PATIIilNT. — ITS REMEDIAL OPEKATION

EITHER ANTIPHLOGISTIC OR REPARATORV. THE FIRST CHIEFLY

DISPLAYED IN THE INFLAMMATIONS OF TROPICAL CLIMATES.

PARALLEL FORMS OF INFLAMMATION HARDLY KNOWN IN THIS

COUNTRY. WHAT COME NEAREST TO THEM. THE EFFECT OF

MERCURY IN THESE NOT ALONE, BUT CONJOINTLY WITH
BLEEDING. — THE PROBABLE NATURE OF ITS ANTIPHLOGISTIC
OPERATIONS INFERRED FROM ITS EFFECTS, ESPECIALLY IN TWO

KINDS OF INFLAMMATION. ITS REPARATORY OPERATION

SHOWN BY INSTANCES.

As a further remedy in tlie treatment of endocarditis and peri-
carditis, I would proceed next to speak of mercury. But I
find myself unable to manage this part of the subject intelli-
gibly, without first making you acquainted with my notions of
the use of mercury in inflammation generally.

Upon a matter like this more uniform and settled opinions
than we find might have been expected among medical men.
Some appear to regard mercury as absolutely remedial of
inflammation, and appl}^ it somewhat indiscriminately and
extravagantly, from a too credulous belief of all that has been
reported in its jaraise. And some see nothing remedial in it,
and forego its use altogether, because they look for a more
exact measure of its benefit in each particular case than it is
possible to obtain.

But men of experience surely cannot difier thus widely :
I mean that sort of experience which belongs to the subject.

Those who are largelj'- conversant with inflammation in its
graver forms, — such as it often appears in hospitals, — and are
much engaged in treating it, must have made or witnessed

158 CLINICAL MEDICINE. [lECT. XIII.

frequent trials of mercury for its cure. And among such, who
possess the needful experience, while there would probably be
found different degrees of confidence in it as a remedy, none
would deny to it all curative pOwer whatever.

Now I venture to offer the following considerations, hoping
that they may serve to reconcile in some degree discordant
opinions, and to show hoiv far and for what mercury may be
trusted in the treatment of inflammation.

First, then, it is quite certain that mercury is not applicable
to all cases of inflammation alike. In some it is eminently
remedial ; in some less obviously so ; and in some it is not
remedial at all. Therefore, besides the fact of the inflamma-
tion, there must be conditions annexed to it, which aid or
insure its efiicacy.

What are these conditions? I do not know that I can
clearly point them out. But perhaps I can tell you where to
look for them.

You are to look for them, then, not only in the inflamma-
tion itself, but also in the part on which it falls, and in the
constitution of the patient.

The condition which respects the inflammation itself is
probably contained in its greater tendency to certain results.
I*J"ow inflammation tends to the deposition of lymph, and to the
effusion of serum and of blood, and to suppuration. And all
these results are often foimd to occur equally and in quick
succession, or almost simultaneously ; but often one or other is
the predominant or almost exclusive result. Accordingly, in
different cases, inflammation will bear to be called adhesive,
or serous, or ha^morrhagic, or suppurative. And the more it
is adhesive, or has its tendency to the deposition of lymph, the
more does it admit the curative impression of mercury.

That over and above this predominant tendency of the
inflammation itself, there is some condition belonging to the
nature of the part, which favours the remedial operation of
mercury, would seem highly probable. For all experience
bears testimony to its more general utility in inflammation of
serous than of mucous membranes. In pleurisy, in peritonitis,
we are accustomed to give merciiry without much discrimi-
nation of the kind of inflammation we have to deal with, or
whether its predominant tendency be to lymph, or serum, or

LECT. XIII.] MERCURY IN INFLAMMATION. 159

pus, or blood; and success lias attended the practice. But in
tracheal and bronchial inflammation we seldom give it, and yet
the majority of cases do well without it.

Still there may be a doubt, whether what we ascribe to the
part may not be all included in the nature of the inflammation.
For in serous structures its tendency is almost always to deposit
lymph. In pleurisy and peritonitis, whatever else be found,
serum, or pus, or blood, it is all involved in false membranes ;
whereas in mucous structures its tendency is almost always to
mucus or muco-purulent effusions. But occasionally, although
very rarely, laryngeal, tracheal, and bronchial inflammation
has its sole and entire result in the deposition of lymph ; and
then mercury becomes the remedy upon which we mainly rely
for its efiectual cure. The very exception points rather to the
nature of the inflammation than to its seat.

But whatever may be thought of one sort of inflammation
rather than another, and of one inflamed part rather than
another needing mercury and favouring its effect as a remedy,
there are states of constitution which aid or hinder its curative
operation in a remarkable manner.

Now the constitution which bears mercury the best, and
most readily accepts and appropriates all the good it is capable
of doing, is that which is naturally and habitually the most
healthy and the most free from all specific taint or weakness,
whether hereditary or acquired. When in such a constitution
inflammation is met with, it commonly arises from accident ;
but having arisen, it partakes of the nature of the subject. It
is simple and vigorous, and speeds on rapidly to its destined
results. Inflammation in such a constitution would never be
cured, if the same strength which sustains the force of the
disease did not sustain the greater force (for greater it must bej
of every counteracting remedy, of bloodletting and of depleting
methods in all their kinds, and especially of mercury.

The constitution which bears mercury the worst, and is
most apt to convert the good it might do into evil, is that which
is habitually unhealthy, and has acquired or inherited some
specific taint or weakness, as scrofula. When inflammation is
met with in such a constitution, it either proceeds from some
slight provocation, or arises spontaneously out of the morbid
habit of the subject; and having arisen, it still partakes of the

160 CLINICAL ]^IEDICINE. [leCT. XIII.

same as it goes along. Its course is unequal and precai'ious,
not steadily tending to any certain result. All remedies
applied to it are of doubtful efficacy. The same weakness which
is unequal to carry on the disease cannot sustain the forcfe of
simple antiphlogistic remedies, and is especiallj^ abhorrent of
mercur}'.

But is mercury to bo altogether forbidden as a remedy for
inflammation in scrofulous constitutions ? I am far from saying
so. For even in them I have sometimes seen inflamed organs
plainly and palpably rescued from destruction by mercurj^
pushed to salivation.

But then the cases were peculiar. The inflammation had
been unnaturally vigorous and rapid for the constitution in
which it was found, as if it came from some violent irritation
forcing for the time a feeble body into actions (as it were)
beyond itself, and enabling it to bear for the time extraordinary
remedies, and mercury among the rest. Thus phrenitis, peri-
tonitis, or pleurisy suddenly developed and rapidly progressive,
in the most scrofulous subjects, should have the chance of
benefit from the mercurial treatment.

These, then, are some of the conditions in the disease itself,
in the part it occupies, and in the constitution of the patient,
which seem to favour the success of mercury, as a remedy for
inflammation.

Further, some little insight has been gained from experience
into the mode of its curative operation.

I believe that mercury has two ways by which it contributes
to the cure of inflammation. In the one it constrains the
morbid energy of the blood-vessels, and counteracts the powers
by which the inflammation is carried on. Thus it takes its
place in the same rank with bloodletting. In the other, it
aids the reparation of parts by promoting the removal of stib-
stances foreign to them, whether fluid or solid, which inflam-
ination has produced and left behind. Thus it displays a power
different in kind from that of bloodletting, and coming into
operation, and having its work to perform, after bloodletting
has done all it can. Let us call the first the anttphlogldic, and
the second the reparatory, operation of mercury, and consider
each separately.

The purely antiphlogistic power of merciiry is displayed

LECT. XIII.] MERCURY IN INFLAMMATION. l()l

most eminently in the inflammatory diseases of intertropical
climates. Here the race is fairly run between the actions and
movements raised within the body by the disease, and the
counter-actions and counter-movements raised by the remedy.
The work of destruction by the disease is the work of a day or
two. And the work of a day or two must be the work of
counter-action by the remedy. Even within this time mercury
must be made to salivate, if mercury is made to cure. If the
disease outrun the remedy, the patient dies ; if the remedy out-
run the disease the patient is saved. And all that respects the
disease, and all that respects the remedy, is so marked, so
sudden, and so forcible, that physicians neither doubt nor reason
about the matter. They see what happens, and resting upon
the evidence of what they see, they know that the disease is
cured by mercury.

Yet hardly more certain is the fact of the cure by mercury,
than the manner in which it exercises its curative operation.
For, when mercury arrests and cures these frightful inflamma-
tions of the tropics, it is plain that its power is expended upon
the actions of the disease in controlling them, not upon the
efiects of the disease in inducing their reparation. The efiects,
if the disease go on to its effects, are such as admit of no
reparation. Organs are found mashed, dissolved, and fallen in
pieces, with hardly a trace of their elementary structure left,
when the patient dies.

Our knowledge of this purely antiphlogistic power of mer-
cury is new knowledge, almost within our own times. We are
indebted for it mainly to our own countrymen practising within
the tropics, and a large amount of gratitude is due to them
from all mankind.

Now, what mercury could do in India, it was naturally
supposed capable of doing in Europe ; and experiments were
not long wanting to put it to the test.

It was about the time I was a student, that mercury was
first greatly talked of and greatly employed as a remedy for
acute inflammation in this country. And it has been so talked
of and so employed from that time to the present. In the
meanwhile experience has been growing ; and now, perhaps,
the use and amount of its antiphlogistic power are settled as far
as they ever can or ever will be.

11

162 CLINICAL MEDICINE. [lECT. XIII.

With us inflammation never, or very rarely, begins and
runs on and terminates exactly after the pattern of Indian
inflammation. It comes nearest to it, when it puts on its
acutest form, and attacks vital organs. And in such inflamma-
tion mercury has been administered something after the Indian
mode and measure, and has obtained results which display
satisfactory proof of its antiphlogistic power. So satisfactory,
that, for the sake of this power which they believe it to possess,
a majority of the most experienced physicians in England at
this day would be found employing mercury and pushing it ta
salivation in the earliest stages of acute phrenitis, pneumonia,
pleurisy, and peritonitis.

If I am told that phrenitis, pneumonia, pleurisy, and peri-
tonitis in their acutest forms have been cured by other means,
before mercury was yet known to have an antiphlogistic power,
or had ever yet been given with an antiphlogistic aim ; that
they have been cured by time and copious blood-letting, and so
may be cured again ; I admit the fact. If I am further told,
that the stoutest advocates for the use of mercury dare not
leave such cases to mercury alone, but employ it concurrently
with blood-letting, I admit the fact.

But questions of practical medicine are not to be settled
like points of casuistry. The logical inference from the result
of certain cases may incline one way, and the general mass of
experience may incline another.

In this, that, and the other case of phrenitis or peritonitis,
pneumonia or pleurisy, the patient is largely bled and rapidly
salivated, and is quickly well ; and in all this perhaps you find
no sure warrant for believing that mercury contributed any-
thing to the cure ; or, perhaps, you infer confidently that the
cure was altogether due to the blood-letting ; for in other
cases bleeding alone has been employed, and recovery has
followed.

"Well ! as far as tlie particular cases go, I cannot venture to
say that your inference is wrong. Still my practice must be
governed by the sum of my experience. And the sum of my
experience is this, that the acutest forms of these inflamma-
tions are arrested more surely and more speedily by bleeding
and mercury conjointly than by bleeding alone ; and not only
more surely and speedily, but by a less loss of blood ; in short,

LECT. XIII.] MERCURY IN INFLAMMATION. 163

that mercury does not supersede blood-letting, but tbat it aids
its antiphlogistic power, and yet spares its amount.

Now, in the popular notion, the acutest inflammation is that
which displays the greatest power and force of vascular action
and the greatest febrile heat, and which works its local changes
upon the part affected with the greatest rapidity. Such inflam-
mation we have been contemplating.

But there is inflammation which works its local changes
with extreme rapidity, and yet rouses the movements of the
general vascular system little, or not at all ; nay ! even some-
times depresses them, and raises little or no febrile heat. By what
name would you characterise this inflammation ? As respects
its general vascular action and its fever, acute it is not. Yet,
as respects its local morbid processes, its efiusions of serum,
lymph, pus, and its dangerous or destructive disorganisation,
acute it is indeed. But, by whatever name you call it, by what
remedies would you treat it ? If by bleeding at all, it must be
by local bleeding, and sj)aringly and cautiously even by that.
There is no great and palpable force of action in the disease,
and therefore no great and palpable force of impression needed
in the remedies. But there is a destructive disorganising pro-
cess rapidly at work, which needs to be rapidly overtaken and
counteracted. And this (as I well know) is often efiected by
mercury.

Thus phrenitis and peritonitis, pneumonia and pleurisy are
seen to hurry on their destructive processes, making no show
of energy and power, and bearing and requiring loss of blood
sparingly or not at all ; yet curable, and often cured, by mer-
cury.

Now reflect for a while upon what has been said. Here are
two forms of acute inflammation, both alike, yet both difierent,
and mercury having a share in the cure of both, but not an
equal share. Think what these inflammations are, and Iwio
mercury is brought to bear upon them, and perhaps you will
gain some little insight into the nature of its remedial operation.

In both, the essence of the disease within the part is the
same, equally rapid, equally destructive, and tending to iden-
tical results ; but the accompanying conditions in the con-
stitution at large are difierent : in the one great febrile heat
and great excess of vascular action ; in the other little or no

164 CLINICAL MEDICINE. [lECT. XffT.

febrile heat, and a defect rather than excess of vascular action.
In the first, there is the disease, and much beyond it, the result
of sympathy reaching to all the nerves and all the blood-vessels
throughout the body. In the second, there is the disease and
the disease alone, carrying on its own essential morbid processes
within the part. Blood-letting is a remedy for the first, and
sometimes the sole and exclusive remedy. It subdues the high
vascular action and febrile heat, and, reaching the disease
within the part through the constitution, it subdues it also, and
so compasses the entire cure. But while blood-letting is a
remedy for the first, it may not be the sole and exclusive
remedy. It may subdue high vascular action and febrile heat,
and not at all arrest the disease within the part, or it may
restrain it a little but not subdue it, and it may need the help
of mercury to complete the cure.

Mark then ; it is upon the very essence of the disease, upon
the essential morbid process within the part, that the remedial
power of mercury is brought to bear.

In the second, blood-letting is a less prominent and a less
needful remedy, and mercury has a larger, and a more poten-
tial and more intelligible share in the cure. For here, too,
and here more unquestionably, its remedial operation is, and
must be, counteractive of the disease within the part, and of it
alone. For the disease within the part is the whole disease.

Well, then, from the share which mercury seems to have in
the cure of these two forms of acute inflammation, what is the
little insight (for it becomes us to speak modestly in such a
matter) to be gained into the nature of its operation as an.
antiphlogistic remedy ? It is this ; that, whereas some remedies
act upon the heart and pulsating arteries, and so become anti-
phlogistic by subduing their impulse, or moderating its excess ;
others upon the nervous system, and so become antiphlogistic
by abating irritation and pain ; and others act upon glands and
upon various organs which secrete, and so become antiphlogistic
through derivation or sympathy, mercury acts upon the extreme
blood-vessels. And these are the immediate instruments of the
disease ; and so mercury becomes antij)hlogistic by a mode of
impression which directly interferes with the inflammatory
process itself.

But mercury is reparatory as well as antiphlogistic. "When

LECT. XIII.] MERCUEY IN INFLAMMATION. 165

inflammation has not been withheld from reaching some of its
results, and these have done injury to the structures it has
occupied, injury, however, not altogether irreparable or pre-
sently destructive of life, then mercury is among the remedies
which have power to call into action those wonderful capacities
which nature has provided for her greatest need. It now
belongs to mercury among other remedies to aid and hasten
and render more effectual those operations of the part and the
constitution, by which organs are entirely or partially restored
to soundness, and life is saved.

When phrenitis has reached hydrocephalus, or peritonitis
abdominal effusion ; when pneumonia has reached hepatisation,
or pleurisy hydrothorax, then mercury is among the remedies
which have a power of stimulating the absorbents to remove
the matter extraneous to the blood-vessels whether fluid or
solid, and so of restoring the diseased structures to the con-
ditions of health. Therefore in this state of things it is high
time to give mercury, if it has not been given before ; or if
mercury has been employed at every previous stage, there is
now as much need of it as ever. Whether, pending the in-
flammation, the chance of benefit, from the antiphlogistic power
of mercury has been thrown away, or whether it has been made
the most of, and has not succeeded, there is its reparatory power
still to look to, which may make up for the fault of our practice
in the one case, and the failure of our practice in the other.

But as, with its antiphlogistic power, mercury has some-
times a smaller and sometimes a larger share in the cure of
inflammation ; so, with its reparatory power, it has sometimes
many auxiliaries, and is sometimes itself almost all in all.
There are cases in which, under the use of purgatives and
diuretics and counter-irritants, the effused serum or lymph is
daily becoming less and less ; and when salivation arrives it
is difficult to determine how much mercury contributes to
insure or complete the reparation which had already begun,
and proceeded to a certain point. And, again, there are cases
in which serum and lymph abide undiminished in cavities, on
surfaces, and among interstitial textures, in spite of many
remedies; yet no sooner does salivation appear than they
forthwith begin to be absorbed, and continue to be absorbed
rapidly until they are entirely gone.

166 CLINICAL MEDICINE. [lECT. XIII.

This distinction between the antiphlogistic and reparatory
powers and operations of mercury is simple, and intelligible,
and (I believe) true. It has not been plainly stated, but it has
been plainly acknowledged by the common practice of medical
men, and confirmed by their experience. I am sure it will be
usefully borne in mind. For there are no conditions more
essential to the success of our practice than these ; namely, first
to understand the purposes which a remedy is able to fulfil,
be they few or be they many, and then to have clearly in view
those for which it is needed in the particular case, and then
steadily to point it and press it to its mark.

But, though they may be distinct in kind, it is not always
easy to determine where the antiphlogistic operation of mercury
ends, and its reparatory operation begins. And truly they are
often both required and both displayed in the same case. Where
mercury is needed and given to abate or arrest inflammation in
its earliest and most active stages, it is commonly still needed
and still given in its decline. The best and most efiicient
treatment of inflammation is seldom so absolutely successful,
but that something is left for reparation before the organ can
be said to have acquired its perfect soundness.

LECT. XIV.] MERCURY IX INFLAMMATION. 167

LECTURE Xiy.

SUBJECT CONTINUED. ANTIPHLOGISTIC AND REPARATORY POWER

OF MERCURY OVER ACUTE INFLAMMATION FURTHER ILLUS-
TRATED BY ITS EFFECTS IN IRITIS, OVER CHRONIC INFLAMMA-
TION BY ITS EFFECTS IN RHEUMATIC OPHTHALMIA. — ITS

EFFECTS UPON INTERNAL CHRONIC INFLAMMATION. OUR

ASSURANCE OF THE SEAT IS GENERALLY GREATER THAN IT IS
OF THE ESSENCE OF INTERNAL CHRONIC DISEASES. OUR CON-
CLUSIONS, THEREFORE, LESS CONFIDENT RESPECTING THE

EFFECTS OF MEDICINE UPON THEM. EXPERIENCE OF THE

CURATIVE EFFECTS OF MERCURY IN MANY HIDDEN DISEASES,

WHICH FROM CIRCUMSTANCES ARE DEEMED INFLAMMATORY.

NOTICE OF A PRINCIPLE TO BE REGARDED IN THE MODE OF
ADMINISTERING IT.

All that has been said of the uses of mercury, both as an
antiphlogistic and a reparatory remedy, will be found to have
its best illustration in the inflammatory diseases of one par-
ticular organ. And that organ is the eye. And if any of you
have imbibed an unlucky scepticism respecting the curative
powers which belong to mercury, a month's diligent attend-
ance and observation at the Eye Infirmary will be sure to
disabuse you of it. The eye might have been intended to
furnish us a little model for studying processes of disease and
processes of reparation as they go on in all parts of the body,
so admirably does it answer this purpose.

In the eye we may behold the miniature of all diseases ; for
here nature has displayed, as in a glass, all the little intimate
details of her own wonder-working powers ; her modes of dis-
organising, and her modes of repairing; and the aids which
she receives, and the impediments which she sustains, from the
right and wrong application of medical agents.

Let us take the iris, its inflammations, and their cure, and
dwell upon them for a while. There are cases of iritis in which

168 CLINICAL MEDICINE. [lECT. XIV.

the entire cure is achieved by blood-letting alone. The fact
cannot be denied. But such cases are rare. And there are
cases in which the entire cure has been compassed by mercury
alone. Neither can this fact be denied. But such cases like-
wise are rare. The vast majority of cases which have ter-
minated in a restoration of the organ to its perfect structure
and functions have been treated by both. Experience is so
decisive upon this point, that it would be morally wrong to
come to the treatment of any particular case with the purpose
of trusting exclusively to either.

Truly there is enough for both to do. And with a little
attention you may see clearly what it is that each really does,
and may apportion to one and the other the exact share that
belongs to it in bringing about the result.

Now blood-letting and mercury have not the same relative
share of the cure in all cases. In one, blood-letting has a very
large share, and mercury a very small one ; and in another,
the two remedies have their proportionate shares inverted ;
while in neither case could either of the remedies be dispensed
with.

In very acute iritis where, besides the iris being discoloured
and covered or studded with lymph, and besides the irregular
pupil and the vascular zone around the cornea, the sclerotic is
streaked with blood-vessels and the conjunctiva is as though
injected with vermilion, blood-letting is demanded ; even veni-
section, if the pulse be hard and full, and cupping upon the
temples, if it be not.

And how much does the blood-letting in such a form of
iritis usually effect ? It changes the general aspect of the eye.
It empties the blood-vessels of the sclerotic and conjunctiva.
All that was vividly red beyond the margin of the cornea
becomes paler. But all within this limit remains the same;
the zone round the cornea, the lymjjh upon the iris, and its
discoloration, and the irregular pupil all remain the same.
Blood-letting has abated or subdued the inflammation so far as
it has exceeded the bounds which essentially belong to it as an
iritis. But within those bounds it has not reached it remedially
in the smallest degree. "Within those bounds, in spite of the
blood-letting, the inflammation is still proceeding uninter-
ruptedly to its results. The points of lymph go on enlarging

LECT. XIV.] MERCUKY IN INFLAMMATION. 169

themselves into masses, which more and more lill the anterior
chamber, and close the pujjil, and more and more involve iris,
and cornea, and crystalline lens in one indiscriminate disor-
ganisation.

But add the xise of mercury to blood-letting in the treatment
of iritis in this, its acutestform ; and, besides a visible emptying
of blood-vessels in the entire organ, there will, as soon as sali-
vation arises, be a visible change in the condition of parts within
the proper sphere of the inflammation. Whatever stage the
inflammation has reached, there it will pause. Then the cluster
of blood-vessels, which tended to the margin of the cornea, will
become paler and paler, and the vascular zone will be seen to
fade, and the drops of lymph which studded the surface of the
iris will cease to increase, and then begin to lessen, and then,
gradually disappear. In the mean time, the aqueous humour
becomes clearer ; the i)upil, which was rendered irregular by
partial adhesions, recovers its circular form, and vision is
perfectly restored.

But in iritis, when the general aspect of the eye is not vividly
red, and when the general vascular system is not roused into
fever, and there is no hardness of the pulse, and yet, never-
theless, within its own specific limits, the inflammation is
carrying on its own essential processes actively, rapidly, and
destructively, and the zone encircles the cornea, and the iris is
covered or studded with lymph, which is daily becoming more
and more, and the pupil is irregular or fixed ; then there is
small need of blood-letting, and only of local blood-letting at
most ; but the need of mercury is as great as ever. We cup or
we apply leeches ; and the good that we thus do is seldom imme-
diately apparent. It is not until the mouth becomes sore, that
any visible change begins in the conditions of the disease.

Here, whatever may be due to cupping or leeches, observa-
tion cannot be wrong in assigning the larger and more appre-
ciable share of the cure to mercury.

Such is the strong testimony which practical experience can
furnish to the antij)hlogistic and reparatory powers of mercury,
when it is brought to bear upon acute inflammation. By acute
inflammation, I mean that which carries on its disorganising
processes rapidly, and which works manifest change and detri-
ment within the structure of parts from day to day, whether it

170 CLINICAL MEDICINE. [lECT. XIV.

be accompanied by mucli excess of action in the vascular system
at large, and much febrile beat, or bj'' little or none at all.

But mercury is capable of an antiphlogistic and reparatory
impression upon chronic inflammation. By chronic inflamma-
tion, I mean that which carries on its disorganising processes
so slowly that the amount of change and injury it does to the
structure of parts is not appreciable from day to day. It is
also the characteristic of this inflammation to abide long in one
stage before it passes on to another.

JNTow this general tardiness of its progress, and this lingering
in its several stages, give leisure and opportunity for learning
the effects of remedies upon it. Thus, some remedies are found
to act curatively in one stage rather than another, and others
to act curatively alike in several. Among the last is mercury.
When chronic inflammation abides long in the stage of mere
vascular repletion, mercury will often arrest it there, so that it
shall finally cease before it has proceeded to effuse serum or
lymph. In those forms of ophthalmia called rheumatic, the
special redness of the sclerotic and the vascular zone, and the
general redness of the conjunctiva, after they have long existed
together with their characteristic pain, and have long refused
to yield to other remedies, have often gradually yielded to
mercury, producing salivation.

And in the same forms of inflammation, now advanced to a
more onward stage, the hazy cornea, and the turbid aqueous
humour, and the discoloured iris, and the irregular pupil, have
been gradually cleared up, and been restored, as the mouth has
been gradually made sore by mercury.

But in the whole range of diseases, the cases are few in
which we can gain sensible demonstration of what is going on
within the part. Most frequently we are obliged to reason and
to calculate and learn from the manner in which function and
sensation are effected, what is the part, and what is the disease,
and what is the fittest remedy. Yet, without doubt, the little
that falls within the reach of the senses, is the best and readiest
help to much more that lies beyond them. Thus the visible
forms of chronic inflammation, and their visible cure by mercury,
exemplified in the eye, suggest what many forms of unseen
chronic inflammation are likely to be, and the probable success
of mercury for their cure. Accordingly mercury has come to

LECT. XIV.] MERCURY IN INFLAISLMATION. 171

have a frequent place among the remedies of such Inflammation
when it is believed to exist.

Still to draw our instances from the eye, vision is often lost,
or impaired in various degrees, where we do not discern the
actual disease, but believe it to be seated in the optic nerve or
the retina, and where, from circumstances attending the loss or
impairment of vision, we conceive the disease of the retina or
optic nerve to be chronic inflammation, or some of its effects.
This notion of the disease at once points out the remedy. And
it is remarkable in what numerous instances of amaurosis vision
has been gradually restored by mercury pushed to salivation.
The success of the remedy plainly denotes the nature of the
disease. In many such afiections medicine would be absolutely
without resource but for mercury.

But to draw our instances from other organs, there are nume-
rous affections of the limbs in which sensation or voluntary
motion, or both, are perverted, impaired, or lost ; and numerous
mental affections, in which intellect and moral perception are dis-
turbed, or injured, or annulled. The disease, without doubt, is in
the spinal marrow, or in the brain. But of what kind is it ? Often
the history of the patient will tell us something, his habits, his
mode of living, or injuries, accidents, and by-gone complaints
which have befallen him ; and often the history of his symptoms
will tell us more, — how they began, and how they have pro-
ceeded hitherto, and what has done good and what has done
harm ; and all these together may point strongly to chronic
inflammation. And happily this chronic inflammation may be
still lingering in some stage short of that disorganisation which
is destructive and irreparable.

Upon these fair presumptions the treatment has been insti-
tuted, and mercury has been employed among other remedies,
and salivation has been gradually produced and long maintained ;
whereupon the symptoms have gradually cleared up and finally
disappeared altogether.

Many of the most satisfactory examples which I have seen of
the curative powers of mercury, have been furnished by these
forms of disease, in which I considered that I had chronic
inflammation to deal with.

But let me be very careful of misleading you. Very many
have been the instances in which I have seen mercury utterly

172 CLINICAL MEDICINE. [lECT. XIV.

fail to exercise auy curative impression whatever, wliere the
presumption of chronic inflammation has been as strong as
possible, and where the fact has been put beyond a doubt by
examination after death.

The truth is, that chronic inflammation, in organs remote
from observation, often proceeds so much by degrees and so
covertly, as to give no intelligible notice of itself, until it has
already reached results which are irreparable. The steps and
stages of chronic inflammation are not to be distinctly traced
and calculated except by the eye.

Again, very many have been the instances in which the
treatment by mercury and other antiphlogistic remedies has
not succeeded for the cure of supposed chronic iuflammation ;
because, in fact, no such inflammation has existed, but some other
disease, in its own nature incurable.

Now when a disease is thus taken and treated for inflamma-
tion, and turns out to be no such thing, and taken and treated
for curable, and turns out to be incurable, there is ignorance no
doubt on our part, or there is mistake, and some may think there
is blame. But it is such ignorance as must be, such mistake as
cannot be helped, such blame as the best and wisest of us all
have no power of escaping. From the nature of things it cannot
be otherwise.

There were at the same time under my care in the hospital,
two men completely paraplegic. Both had lost sensation and
voluntary motion of the lower extremities by slow degrees. This
was all that could be said of their symptoms. In neither of
them was there any fever, or vascular excitement or pain.
From the account which they gave of themselves, there was
reason to believe that the disease of both had originated in
exposure to cold some weeks ago, and that that disease was
chronic inflammation of the spinal marrow, or its coverings.

Both were treated by the same remedies, by counter-irritants
to the spine, and by mercury. In both, salivation was gradually
induced, and was long maintained.

Well, what were the results ? One patient, as soon as the
mercury gave notice of its specific eflfect upon the constitution,
showed an earnest of improvement. Sensation and the power of
motion returned very slowly, but at last very completely, to his
limbs, and after three months he walked out of the hospital

LECT. XIV.] MERCURY IN INFLAMMATION. 173

well. The other never showed the least sign of improvement,
and, after lingering in the hospital for many months, he died.
Upon examination a small scrofulous tumour was found growing
from the theca, and pressing upon the spinal marrow.

JSTow I can fancy an uninformed looker-on coming to a very
unjust judgment upon these results, and giving a very unjust
award of praise and blame accordingly ; applauding what he
miffht take for a clear insiffht into the nature of the disease in
the one case, and the consequent success of its treatment, and
censuring what he might take for ignorance and mistake, and
consequent failure, in the other. But there is neither praise
nor blame in the matter. You cannot be sure of the success of
your remedy, while you are still uncertain of the nature of the
disease, as you must be here.

The diagnosis of disease is often easy, often difficult, and
often impossible. Why it is so, would be a most interesting
and profitable inquiry ; but a very large one too, much too large
for us at present. But I must just touch upon one part of it
(the part which here concerns us), and try to show how it happens
that the diagnosis of disease is often absolutely impossible.

All diseases are known by their symptoms ; and all symptoms
may be regarded under two general aspects, viz. those which
denote the disease in its essence, and those which denote the
disease in its seat. Thus, inflammation has symptoms arising
out of itself as such, which denote it to be an inflammation;
and it has symptoms arising out of the disturbed functions of
the organ it occupies, which denote what that organ is, as the
brain, the lungs, the heart, the stomach.

Now, in proportion as inflammation is more acute and rajjid,
both orders of symptoms are more express and prominent, and
the diagnosis both of what is the disease, and of what is its seat,
is equally certain. But in proportion as inflammation is more
chronic and tardy, the symptoms which flow from its essence
are less and less marked ; they may even become indiscernible,
so that they cannot be said to exist at all. And then the dia-
gnosis of what the disease is, becomes necessarily more and more
obscure, and may be so obscure as to amount to no diagnosis at
all. Yet in the mean time the symptoms which flow from the
part are distinct enough, and become more and more distinct
from week to week ; and thus, while a very obscure diagnosis

174 CLINICAL MEDICINE. [lECT. XIV.

of the nature of tlie disease is all that can be obtained, or no
diagnosis at all, the diagnosis of its seat is clear and undoubted
from first to last.

There is, then, a hard necessity in the case, and there is no
help for us ; while of the organ affected we are certain, at the
nature of the disease we can only guess. Yet in so guessing,
surely we ought to be led by our hopes, and by the possibilities
of doing good. We should always presume the disease to be
curable until its own nature prove it otherwise.

But when the question is of chronic disease afiecting the
structure of parts, to presume that it is curable is tantamount
to presuming that it is simply inflammatory ; and this at once
suggests the use of mercury.

!N^ow, I once heard an old experienced physician say, that
most of the obscure diseases were cured by mercury. This is as
much as to say that most of the obscure diseases are of the nature
of chronic inflammation. It would perhaps be nearer the truth
to say " many," instead of " most," and this would still leave
suflacient encouragement for the employment of mercury.

But one point yet remains to be well considered. I have
spoken already, as we went along, of mercury so given in one
case as to produce salivation rapidly or at once, and so given in
another case, as to produce salivation slowly or gradually. But,
if salivation do but take place, does it matter much to the cure
whether it arise sooner or later ? Yes ! indeed does it. And
this is the very point now to be considered. It is as important
as any to be found in the whole of practical medicine.

Mercury, as a remedy for inflammation, requires to be
administered with as careful an adaptation of its dose to the
exigencies of each particular case, as bleeding does of its mode
and quantity. The principle of practice is this, to measure the
force and rate of the counteractive impression to be produced,
whether by blood-letting or by mercury, by the force and rate of
the disease. If you have an inflammation of the greatest force
and greatest rapidity to deal with, and organic changes are
taking place from hour to hour, and blood-letting is to be your
remedy, its mode must be by venaesection, and its quantity must
be of large amount ; and it may need to be repeated again and
again, and at short intervals. The blood-letting must make
itself felt with a force and a rapidity which shall exceed the

LECT. XIV.] MERCURY IN INFLAMMATION. 175

force and rapidity of the disease, otherwise it is no remedy at all.
So, too, in the same conditions of inflammation, if mercury is to
he your remedy, its dose must be large, and repeated. Calomel
must be given in the dose of half a scruple at once, and again
after six or eight hours. The patient's life may depend upon
his being salivated within a couple of days. The mercury, like
the blood-letting, must make itself felt, by its specific efiects,
more forcibly and more rapidly than the disease, otherwise it
will fail of its counteractive operation.

But if the inflammation be of little force, and slow in its
progress, and its organic changes such as are not visible from
hour to hour, or even from day to day, but rather from week to
week, then if your remedy be blood-letting, its mode must not
be by venaesection, but by cupping or leeches, and its quantity
must be small, and, if it be repeated, it must be at more distant
intervals. For now it is essential to the cure that the counter-
impression of the blood-letting should be kept down to the
small measure of power, and the slow rate of progress, belonging
to the inflammation ; otherwise it is no remedy at all. And
in like manner, if mercury be your remedy, it must now be
given more sparingly and less frequently. The object is to
produce salivation, not as soon as possible, but slowly and with-
out surprise or violence. A grain or two of calomel once or
twice a day, or even some milder preparation of mercury, will
bring its specific effects to bear upon the disease after many
days, but still remedially.

Upon the principle here laid down and illustrated by the
use of bleeding, as it is the important principle which is also
to guide us when we employ mercury for the cure of inflamma-
tion, let me say a few words more.

Partly, I think, this principle would be at once accejsted as
true, and partly it would seem questionable at first sight, and
would need experience to confirm it. That the blood-letting
must be copious, and of the most general kind, and that the
doses of mercury must be large, which are to be counteractive
of severe and rapid inflammation, may be easily conceived. It
looks as if it necessarily must be so. But that the blood-letting
mud he scanty, and of that kind which is local, and that the
doses of mercury must be small, which are to be counteractive
of the inflammation that proceeds slowly, and is of small power,

176 • CLINICAL MEDICINE. [lECT. XIV.

would liardly be expected. One sliGuld rather be disposed to
argue a fortiori, that copious blood-letting by venocsection and
large doses of mercury, being able to cure inflammation of great
force and rapidity, could not fail to obtain an easy mastery over
that which is of little force, and proceeds tardily : that small
bleedings and small doses might now be enough, and yet that
large ones would do the business more summarily and at once.
But experience comes in to rectify such calculations, teaching us
this general fact, that small bleedings and small doses of mercury
are undeniably curative in forms of inflammation, where large
bleedings and large doses exercise no remedial power whatever.
A large venaesection will (as it were) leap over the disease
without touching it, and afterwards a few leeches will bring it
safely and gradually to an end. A rapid salivation will pass by
the disease, and leave it unaltered. But when this salivation
has been allowed to wear itself out, and the constitution been
left to forget (as it were) the impression, and to recover from
it, then the remedy being resumed on other terms, and admin-
istered in very small and very cautious doses, has wrought, in
process of time, an easy and efiectual cure.*

* I think it well here to subjoin in a note certain remarks upon condi-
tions favourable or essential to the remedial effects of mercury, which I made
many years ago, when an opportunity had been recently afforded me of
watching its operation upon a pretty extensive scale : —

"As in regard to the various bowel complaints, so in regard to the various
nervous disorders, the condition most essential to the success of the remedy
was unquestionably this, that the force and rate of its impression sliould be
in proportion to the force and rate of the disease. And the chief object of
our care was to preserve that proportion.

" Thus, where the disease was less severe, and was slow in its progress,
salivation (without reference to its degree) was to be procured gradually ;
where tlie disease was more severe and rapid in its progress, salivation
(without reference to its degree) was to be procured at once. Headache and
vertigo, which had come on tardily, and had abided many weeks, without
any perceptible excitement of the circulation, were to be made to yield under
the slow and alterative influence of mercury, which the constitution could
bear without injury. Headache and vertigo, which had been sudden in their
accession, were accompanied with excitement of the circulation, and already
seemed to threaten something beyond themselves, as convulsion, or delirium,
or frenzy, were to be at once mastered by such a sudden and powerful im-
pression of the remedy as the constitution would severely feel. Hence the
•quantity of the remedy was continually varied, according to the exigencies
of particular cases. For some we prescribed one grain or two grains of

LF.CT. XIV.] MERCURY IN INFL.VAIMA TIOX. 177

calomel, with a small quantity of opium, once or twice in twenty-four hours,
and thus succeeded in procuring relief after the lapse of a Avcekor ten days;
doing no harm in the mean time, to the general health and sensations of the
])atient. For others, we prescribed five, or ton, or even twenty grains of
calomel, with proportionate quantities of opium, once, or even twice, in
Iwenty-four hours ; and tlius succeeded in dissipating the symptoms at once,
and in rescuing liA; at the expense of some ])resent injury to tlie constitution."
— An Account of the Disease lately prevalent at the Genend Penitentiary,
p. 113, ed. 1825,

12

178 CLINICAL MEDICINE. [lECT. XV

LECTUEE XY.

USE 01' MERCURY IN THE TREATMENT OF RHEUMATIC ENDO-
CARDITIS AND PERICARDITIS. EVERY GREAT ADVANCE OF

CLINICAL AND PATHOLOGICAL KNOWLEDGE REQUIRES THAT
OLD REMEDIES SHOULD UNDERGO THE TRIAL OF NEW

EXPERIMENTS. IN ENDOCARDITIS THE REMEDIAL POWER

OF MERCURY SHOWN, NOT SO MUCH BY THE RESULT OF
SINGLE CASES, AS BY THE COMPARATIVE RESULTS OF MANY
WHICH HAVE, AND OF MANY WHICH HAVE NOT, BEEN

TREATED BY IT. IN PERICARDITIS ITS REMEDIAL POWER

MAY BE APPRECIATED IN INDIVIDUAL CASES. THE RELATION

WHICH THE CESSATION OF THE EXOCARDIAL MURMUR BEARS
TO THE CESSATION OF THE DISEASE. THE POWER OF MER-
CURY TO PROCURE THE CESSATION OF THE MURMUR, EARLY

OR LATE, ACCORDING TO CIRCUMSTANCES. EARLY SALIVATION

MOST STRIKINGLY CURATIVE. — LATE SALIVATION NOT WITH-
OUT BENEFIT. COMPARISON OF SOME GENERAL RESULTS.

While we Avere considering the treatment of rheumatic inflam-
mations of the heart at each several step, and with the recom-
mendation of each several remedy, I kept your attention alive
to another remedy, which was yet to be noticed. This is mercury.
Bleeding-, in its various forms, must be used, I told you, for its
own direct curative power over the disease ; but so used, that it
should not hinder the curative j)ower of mercury. Opium, I
told you, must be employed to jDacify the nervous system ; but
so employed, moreover, that it should at the same time aid the
curative power of mercury. Then the curative power of mercury
over inflammation in general was considered ; and now we come
at last to its curative power over rheumatic inflammations of
the heart, and I will endeavour to give you as fair an estimate
of it as I can.

Many years ago, in certain Essays which I published " On

LECT. XV.] MERCURY IN CARDIAC RHEUMATISM. 179

some Diseases of the Heart,"* I ventured to insist, that mercury-
pushed to salivation was indispensable to the cure of pericar-
ditis. And at that time I did not insist on less than the results
of my experience, carefully considered, seemed to warrant.
But then my knowledge of the disease was very defective ;
defective esj)ecially in respect of its diagnosis during the life
of the patient ; and so was then every body's knowledge. For
now I plainly perceive that the majority of the cases in Avhich
I then believed myself treating an inflammation of the pericar-
dium, were, in fact, cases of endocarditis.

As diseases are better understood, and we possess surer
signs for discerning their seat and progress, and events, the
records of past experience become obsolete, and so a necessity
arises for a new course of clinical observations. Even each
man's own stock of observations, if in his time knowledge
has made a great stej) in advance, observations which he has
carefully kept in mind, and which have served him to
draw conclusions from, he may, after all, have good reason to
distrust.

What an amazing difference there appears in the objects of
nature around us, according to the point of view from which
we regard them ! When we stand on the right spot for taking
in the whole prospect, we then see what before we could not
see at all, or we then see clearly what before we only caught a
glimpse of, from some less commanding position.

Thus, the point of view from which diseases of the heart
are now regarded, discloses so many new things, and puts so
many old things in a much clearer light, that I distrust the
results of my former experience, and feel the need of submitting
all my practice, and the use of all my remedies, to the test of
my own more recent observations. I feel that the use of
mercury, especially, requires to be brought to this test.

Formerly I gave mercury, or designed to give it, in every
case of pericarditis, and sought to procure salivation, which I
deemed indispensable to the cure. And thus thinking to give
it in every case of pericarditis, I probably gave it also in every
case of endocarditis, not being then able to distinguish one
from the other. But now, when I look back, I plainly perceive
(whatever I might then have thought), that the impossibility
* Med. Gazette, vol. iii.

ISO CLINICAL MEDICINE. [lECT. XV.

of then forming a diagnosis between the two stood in the way
of my gaining a sure proof of the benefit of mercury in
either. The diagnosis, however, between the two, being now
plain and obvious, I will seek the evidence of the use of mer-
cury in the treatment of each separately.
And first, of endocarditis.

In my clinical records, I find some cases of endocarditis in
which bleeding and common antiphlogistic remedies alone were
employed, and not a grain of mercury was given ; and yet all
the symptoms refei-able to the heart, the pain, the palpitation,
the dyspnoea, and the endocardial murmur itself, entirely
ceased. In short, there was all the evidence that could be
required of a perfect cure. But I find no cases in which mer-
cury alone was given, and not a drop of blood was taken, and
uo other antiphlogistic remedy was employed, and yet perfect
reparation followed. While, then, I have facts which claim an
independent remedial power for blood-letting, I have none which
claim the same for mercury.

Again, I find some cases of endocarditis in which bleeding
was used, and mercury given conjointly, and the evidence of
cure was satisfactory ; but the mercury produced no salivation.
Here one cannot tell what share the mercury had in procuring
the result ; one cannot even be sure that it had any share at all.
Again, I find some cases in which bleeding and mercury
were employed conjointly, and salivation quickly followed, and
every vestige of the disease was swept away at once. But
here, the modes in which the remedies took efiect, and the
symptoms ceased, were such, that no opinion could be formed
how much of the cure was due to bleeding, and how much, if
any part of it at all, was due to the mercury.

Again, I find some cases in which bleeding and mercury
vvcre emploj'ed conjointly, and salivation followed, but it was
slow to arrive. And reparation was complete in the end, but
it was after a long time. Here the manner and gradations by
which the disease declined appeared to correspond with the
sensible operations of the remedies, and to denote, with seeming-
exactness, the curative influence belonging to each. The
bleeding was ])ractised, whereupon vascular action immediately
abated much of its force, and pain, and palpitation, and dyspnc8;i
inimediatelv went awav, but the endocardial murmur remained.

LECr. XV.] MERCURY IN CARDIAC RHEUMATISM. 181

Mercury, too, was given from the first, and day after day it
was still o^iven, yet there was no salivation. At length, how-
ever, salivation arose, whereupon the endocardial murmur
ceased.

These several orders of cases exhibit fair specimens of the
sort of difficulties which are apt to obstruct us, when we seek to
analyse the effects of medicines. We may be well satisfied
with the general results of treatment ; but when we betake
ourselves to calculate the separate value of the means by which
these results are brought to pass, we may not be able punctually
to determine what it is.

If I were called upon to bring sure proof of the remedial
power of mercury in endocarditis, the last, perhaps, are the
only cases to which I should be allowed to appeal ; and these
claim for it (what I have explained to be) a reparatory, not an
antiphlogistic power. They do not satisfy us that it had any
thing to do in counteracting the progress of the inflammation.
They only show us that it came in aid of nature in restoring
the endocardium to its integrity, after the inflammation had
ceased.

But although in endocarditis I cannot produce proof, beyond
cavil and exception, of more than a reparatory power belonging
to mercury, yet my impression is so strong that it does exercise,
moreover, a power purely antiphlogistic and auxiliary to blood-
letting, that I dare not omit to give it in every case as soon as
I have ascertained the nature of the disease, and to press it
to salivation.

Analogy favours the belief of its being antiphlogistic as
well as reparatory in inflammation of the endocardium. It is
obviously so in inflammation of some other structures — of the
iris, for instance.

At all events, the reparatory power of mercury in endocar-
ditis is tolerably certain, and the earlier we employ it, the more
likely is this reparatory power to come into effectual exercise.
Mercury being administered coincidently with the use of blood-
letting and other remedies, though it may possibly not add any
antiphlogistic power of its own to theirs, yet in the mean time
it will be making its way in the constitution, and will be ready
to further the work of reparation when the inflammation has
passed away.

182 CLINICAL MEDICINE. [lECT. XV.

Thus, when I take my own experience in detail, and
examine the results of treatment case by case, I cannot pretend
to have found a certain proof that mercury is an indispensable
remedy to the cure of endocarditis. But taking my experience
in the mass, I still fear to omit its employment in any case of
endocarditis with which I have to do.

No doubt, hj bleeding- and other ordinary antiphlogistic
remedies, precordial pain and palpitation, and even the endo-
cardial murmur, have been known entirely to disappear, when
mercury has either not been used at all, or being used has not
produced salivation.

But against the particular result of these cases, as seeming
to exclude mercury, I would set the general result of my
entire experience, as seeming (to me at least) to recommend it.
Since the time that auscultation has disclosed the sure diagnosis
of the disease, it has not in a single instance proved fatal under
my care. But M. Bouillaud, to whom the world is greatly
indebted for bringing its diagnosis to perfection, records
numerous instances in which endocarditis terminated fatally
ujider his management.

Now M. Bouillaud's treatment of endocarditis has always
been vigorously antiphlogistic. He has employed large and
rejDeated bleedings, and all other remedies calculated to control
inflammation, except mercury. Mercury he never used.

My treatment of endocarditis, on the other hand, has not
been vigorously antiphlogistic. I have seldom employed vense-
section at all, and never largely. But mercury has been among
my remedies in almost every case.

From this comparison the conclusion is irresistible, that
mercury has the power of doing something more in counter-
action of inflammation of the endocardium than venisection
and other antiphlogistic remedies, and that upon this something
being done the life of the patient often depends.

What this something is we can only conjecture from
analogy, but yet with great probability of truth. Undoubtedly
it consists either in controlling the disease, or in restoring the
conditions of health, or in both. For these are the only ways,
as far as I know, in which mercury exercises its curative
influence.

Experience thus testifies to the broad fact of mercury being

LEC'i'. XV.] MERCURY IN CARDIAC RHEUMATISM. 183

instrumental to the mrhxj of life in cndocarditi.s. And un-
questionably so it may bo, and yet not carry its curative powers
to perfection in every case. From the records already given,
it will bo seen liow many subjects of endocarditis are brought
through a formidable disease by antiphlogistic and mercurial
treatment, and survive and are safe ; but still they have the
endocardial murmur, and never lose it. Here the mercury has
indeed fallen short of restoring perfect intcgrit}^ of structure,
but it has had its share in saving life nevertheless. Some
unevenness, some thickening, puckering, or shortening of a
valve, or a bead of lymph upon it ; this may be all that
remains. But this is enough to produce an eddy of the blood,
and the eddy to produce an audible murmur, and thus the heart
ever afterwards passes for unsound. Yet any other internal
organ which, from being inflamed, should come so near repara-
tion, would pass for sound, because we should not have the means
of knowing it to be otherwise.

In those diseases where the remedial power of mercury is
least questionable, reparation is apt to take place, leaving
behind a mark or a scar. Thus, the pupil often remains
slightly irregular after the cure of iritis, and clefts remain in
the tonsils after the cure of an ulcer. No evil, however,
results. But the merest scar within the heart is, from the
nature of its functions, a grave matter in its ultimate effects.
Still it is no disparagement of the remedial powers of mercury
here, more than elsewhere.

In conclusion, the simple fact of the much larger propor-
tion of cases in which life is saved where mercury is used than
where it is not, is a plain paramount recommendation of it as
ii remedy for endocarditis, which all can see and understand.

We come nest to the use of mercury in pericarditis. In
■every one of my eighteen cases, complicated and uncomplicated,
mercury was employed. But then it was employed conjointly
with other remedies; so that my experience does not furnish
me with a single case from which I should be allowed to infer
conclusively the curative effect of mercury without the aid of
other remedies, or the curative effect of other remedies without
the aid of mercury. Still I should be sorry to omit the use of
either in any case of pericarditis with which I had to do. Bvit
the question at present is only concerning mercury. And,

181 CLINICAL MEDICINE. j_LECT. XV.

allowing bleeding and common antiphlogistic measures to be
needful, and even indispensable, I am fully persuaded tbat let
tbem do all which they can do, mercury can do something
more; something towards saving life and inducing reparation,
which nothing else can do, or nothing else can do so well. Of
this there is as satisfactor}' evidence as we have of most points
in practical medicine which are thought settled.

Before I come to a closer examination of this evidence, I
would mention one remarkable fact. Of the eighteen cases of
pericarditis, which are the subject of our present commentary,
and W'Cre treated by mercury, some were brought imder its
sensible influence very largely, and some very slightly, but all
in a certain degree except two. In these two cases, though
mercury vras given in large quantity and for a long period, yet
was there no sensible ptyalism, no factor of the breath, no
complaint of soreness of the gums. In these two cases, while
mercury was pushed thus strenuously, other remedies were
vigorously employed; and, moreover, in these two cases every
conceivable circumstance was present which could promise
success to medical treatment. The subjects were healthy sub-
jects and in the prime of life. The disease (there was reason
to believe) was detected as soon as it arose. Not a moment
was lost in the application of remedies. They were venoosection
and cupping and leeches and blisters and opium and, from first
to last, mercury. But the mercury, as I said, did not produce
the peculiar eifects of mercury in the slightest appreciable
degree.

Now of my eighteen cases of pericarditis I lost three; and
these were two of them.

But let us see whether we cannot get a little nearer insight
into what mercury does in j^ericarditis. And let me premise
that in pericarditis the sym^jtoms, both auscultatory and non-
auscultatory, give a more exact intelligence of what is going-
on from day to day than they do in endocarditis; and we are
able to follow the steps of the disease, and to appreciate the
efi'ects of remedies, moi^e surely and satisfactorily. And, as of
other remedies, so of mercury.

Now my strong inijjression is, that jDericarditis, of that
extent and degree which it generally reaches in acute rheu-
matism, though it be treated by the best remedies and in the

LECT. XV.j MERCURY IN CARDIAC IIIIEUMATISM. 185

most opporfiuio and cfiiciont manner, is never so completely
cured that the parts regain their perfect integrity of structure;
in short, that in the most favourable event the pericardium
almost always adheres. Medical treatment saves life, but it
rarely prevents the adhesion.

13 ut then, has the medical treatment of pericarditis no
further aim than barely to save life ? Has it only to provide
that the exocardial murmur should cease, and the patient con-
tinue to live on any terms ? Yes ! it seeks much more than
this. It has, indeed, first to save life; and it has further to
provide that the life which it saves shall go on with the least
possible hindrance, and suffer the least possible abridgment
of its natural duration. And this it does when it arrests the
progress of the disease, and, moreover, provides that the repara-
tion (which I fear is rarel}^ perfect) should take place with the
least possible degree of imperfection; that is, that the folds of
the pericardium should be brought together again, and should
permanently adhere with the least possible quantity of inter-
vening lymph.

When this is brought to pass, remedies have done their
best. But, for the sake of being able to judge how far remedies
are actually doing their best in particular cases, we should
bear in mind, that the final cessation of the exocardial murmur
probably denotes the adhesion of the pericardium, and that the
sooner this occurs the less accumulation of the j^roducts of
inflammation must have preceded it, and the more perfect,
or, rather, the less imperfect, is reparation likely to be in the end.

Thus it is a great thing for the exocardial murmur to begin
and cease in a week. I can refer to three cases only, in which
I am sure that such was the fact. And there was not one of
them in which the jDatient was not first salivated. In two
other cases the exocardial murmur ceased, in one on the sixth,
and in the other on the eighth day, after they were brought
imder my observation and treatment, and in both, the patients
were first salivated; but in them I had no certain knowledge
how long the murmur had been audible before admission into
the hospital. In these several cases not only did the murmur
cease, but the ^^ hole business of medical treatment w'as accom-
plished. With the cessation of the murmur life was apparently
safe, and convalescence followed rapidly.

186 CLINICAL MEDICINE. [lECT. XV.

Here mercury seemed to me to display its highest anti-
phlogistic power. But, if others doubt, let it be a question for
future observation, whether, where the nmrmur of pericarditis
rapidly ceases and the danger rapidly disappears and conva-
lescence rapidly follows, salivation is or is not a preceding
condition, in all, or in the vast majority of cases. There is
no question of practical medicine more important to have
rightly settled.

But I am anxious not to be misunderstood in this matter,
or thought to state either more or less than I mean. My expe-
rience (as far as it goes) tells me, that whenever the exocardial
murmur has ceased early, salivation has first taken place. But
it does not affirm the converse, viz. that wherever salivation
has taken place early, the exocardial murmur has ceased early.
These are very different things. The early cure may not take
place without the early salivation, but the early salivation maij
take place Avithout the early cure.

When, therefore, in after times, you come to treat this
disease, should you sitcceed in bringing your patients speedily
under the influence of mercury, and find in one case a speedy
cessation of the murmur and a speedy arrest of all the more
formidable symptoms, and find in another case the murmur
still remain and still abide for a long time afterwards, and
other formidable symptoms, mitigated indeed, but more slow
to disappear, do not say that I have misrepresented the power
of the remedy. All this is according to my experience; for
turning to my records of cases I find six in which salivation
was rapidly produced, with the following different results as to
the period at which the nmrmur ceased: —

Cases. Days. Days.

1st. Salivation produced in 1 Murmur ceased in 4.

2d. — -1 — 7.

3d. — :3 — 4.

4tli. — 4 — 28.

nth. — 5 — 14.

6th. — 5 — 25.

Of these six cases mercury was most eminently remedial
in the three first, less eminently but still remedial in the three
last. The cessation of the exocardial murmur at such widely
different periods after salivation appeared, is satisfactorily
accounted for by the circumstances of the different cases.

LECT. XV.] ]MERC1I11Y IN CARDIAC RHEUMATISM. 187

In tlie Ihroo first cases mercury was given as soon as the
murmur was audible, and salivation followed in one, two and
in throe days; and the entire duration of the murmur was
four days in the first, seven days in the second, and four days
in the third case. Ilere there was reason to believe that the
murmur denoted the commencement of the disease. The
patients were under observation before the murmur arose.
Prior to it there was no other symptom referable to the heart ;
and thus the remedy had an equal start with the disease. It
was ready to sway and counteract the first inflammatory move-
ment, and still to keep it imder day by da}^ and ultimately to
withhold it from terminating- in more than a scanty efi'usion of
lymph within the pericardium. Thus, when the inflammation
ceased (as it did) quickly, reparation was short and easy; there
was little effused, and little to be absorbed. The folds of the
pericardium soon came together again, and were soon restored
to their previous state, or soon adhered.

In the three last cases, too, mercury was given as soon as
the murmur was audible, and salivation followed in four, in
five, and in five days. But the entire duration of the murmur
was twenty- eight and fourteen, and twenty-five days in each
case respectively. Here there was reason to believe that the
murmur did not denote the commencement of the disease.
Prior to it for some days, and before the patients came under
our observation, there were other symptoms referable to the
heart, — severe pain and anguish and inordinate impulse. And
thus the disease had the start of the remedy. The inflamma-
tion was at first, and still for a while, unchecked and uncoun-
teracted, and ultimately was not withheld from terminating in
a large eflusion of lymph and serum within the pericardium ;
and thus, when it ceased, reparation became long and difficult.
There was much effused and much to be absorbed. The folds
of the pericardium were slow to come together again and slow
to adhere. When acute inflammation has existed only for a
day or two, and has done the mischief only of a day or two,
and the remedy has been brought to bear upon it rapidly,
fvdly, and successfully, then the changes from bad to good may
be plain, palpable, and at once. The symptoms of the disease
may be swept away, and the mischief done in a day or two may
be vmdone in a day or two, and all may soon be well. But

188 CLINICAL MEDICINE. [lECT. XV.

when inflammation has gone on for a week or ten days, and has
done the mischief of a week or ten days, then, though it may
still be within the possibility of cure, it cannot be brought
to yield instantaneously to the curative impression of any
remedy. The changes from bad to good will not be discernible
at once. What it has taken a week or ten days to do, it will
take at least a week or ten days to undo. All may be well in
the end, but all cannot be well speedily.

I*row in these last cases, considering the long interval that
elapsed between the appearance of the ptyalism and the cessa-
tion of the murmur, and considering the fact that other reme-
dies were employed together with mercur}^, I do not pretend
to assign to mercury the exact share it had in procuring the
result, and I can well pardon any man, who is not satisfied
from my mere statement, that it had any share at all. But all
who witnessed the cases were satisfied, from their own observa-
tion, that it had a material share. We were all struck by this
remarkable circumstance, that the whole terror of the disease
was compressed within the few days which preceded the
salivation.

Precordial pain, and anguish, and fluttering, and gasping
for breath, and pallor, and delirium, and nervous exhaustion,
and threatened syncope, all in their extreme degrees, made death
the apprehension of almost every hour, for four days and nights
in one case, and for five days and nights in the two others.
But though the murmur still continued in one case twenty-four
days, in another nine days, and in another twenty days after the
salivation, yet no sooner did it take place than the terror of the
disease was gone. Henceforth the cases still needed anxious
watching, and still needed careful treatment. But it was treat-
ment of a difierent kind, and upon different terms. It was such
as, instead of continually applying and pressing remedies to
counteract progressive inflammation, kept them in reserve, and
brought them to bear upon this or that distressful symptom as
it happened to arise. The inflammation seemed gone, but its
cfiects remained ; and both the constitution and the heart itself
required some helps of medicine, that they might be enabled to
sustain them until such reparation as was possible should be
finally accomplished.

(Such are the remedial effects of mercurv, when it enters

LECT. XV.] MHRCIJIIY IX CARDIAC RtlElJMATrSM. 189

into the treatment of pericarditis, tind produces salivation
rapi(U)j.

But mercury may enter into tlic treatment of pericarditis,
and produce salivation slouch/, even very nlowly. It so happened
in five of tile cases whicli fell under my care. In one it took
eight days, in two eleven, and in two, thirteen days to procure
ptyalism or fiietor of the breath or soreness of the gums.

Now in all these cases, bleeding and other antiphlogistic
remedies and opium were meanwhile employed from day to day,
and with good effect. They kept down vascular and nervous
excitement, they assuaged pain, they abated palpitation ; and in
the end the exocardial murmur ceased, and life was saved.

These cases, perhaps, you would throw aside at once, and
think it a foolish fancy to be searching into them for proof of
any remedial power of mercury. Perhaps you would think that
to those other means of acknowledged power and efficacy, which
did manifest service from day to day, must be justly ascribed
the whole credit of finally saving life and inducing reparation,
and that to mercury, which produced no sensible effect imtil
eight, or eleven, or thirteen days were past, cannot reasonably
be due the smallest share in the result.

Nevertheless, I must profess my strong persuasion that mer-
cury had a share, and an important one, in the result.

In all the five cases common antiphlogistic remedies were
fairly and fully employed ; and, when no salivation appeared
after many days and it became more and more doubtful whether
it would ever take place, they were used with the more earnest
purpose of making them do all they could do, as if the whole
cure depended upon them, and as if there was no other remedy
in reserve, no mercury, which might yet come into operation at
last, and complete the work which they had left imperfect.
Now what ha])pencd ? Not in a single instance of all the five
was there the best and surest evidence of inflammation arrested,
and reparation begun, until mercury, though late, had produced
its specific effect. Not in a single instance did the exocardial
murmur cease to be audible, until salivation appeared.

Hecollect the common antiphlogistic remedies had already
had in one case eight days, in two cases eleven days, and in two
cases thirteen days allowed them, to do all that they could do
alone. And it is strange, indeed, that in some one or two at

190 CLINICAL MEDICINE. TlECT. XV.

least of these cases they should not haxe procured the cessation
of the murmur, if they alone were capable of procuring it,
before the salivation arrived.

This is a fact worth noticing ; but it is merely a negative
fact, and cannot be pressed to bear testimony to the comparative
efficacy of this or that remedy. As to the exocardial murmur,
though it ceased at last in all these cases, yet it continued in
every one of them for a long time after salivation had taken
place, in some for several days, and in some for more than a
week. But, prior to its cessation, there were signs which gave
us assurance of inflammation being brought to an end, and of
life being saved ; and these were so coupled with the occurrence
of salivation, that it would have been unreasonable to doubt of
mercury being mainly instrumental to the result.

I will relate, then, summarily, the plan of treatment, and the
progress of recovery in these cases, marking the changes conse-
quent upon the impression of the several remedies, and of mer-
cury among the rest.

At the beginning, every thing seemed favourable to the cure.
The treatment commenced with the administration of mercury
in the way best calculated to insure its specific effect, and pro-
ceeded, without remission of its use, day by day. And from the
first, also, and day by day, vena^section, or cupping, or leeches,
blisters, and opium, were employed, according as indications
required them. And these fulfilled their immediate j^urposes.
Pain, and anguish, and dyspnoea, and palpitation, were relieved.
Yet there was no salivation. But pain^ anguish, dyspnoea, pal-
pitation, all, or several of them, returned ; and they were again
relieved by some, or by several of the same remedies. Yet still
there was no salivation. And again, in lilce manner, the same
symptoms returned, and again were relieved by the same
remedies. Yet even still there was no salivation.

But after several times thus going and coming, the symptoms
became more and more modified by weakness, and at last fearfully
so. And after several times thus giving relief, the remedies
gave relief less and less, and at last not at all. Thus medicine
seemed at the end of its resources, and the patient sure to die.

Now at the commencement of the disease, when mercury had
been given for two or three days, and no salivation aj)peared,
other remedies (it has been said) were pressed more earnestly

LECT. XV. J MKliCT'RY TN (.\UiI)IAC RHEUM ATIS.M. 191

and vigorously, from an apprclioiision tliat our sole dopondoncc
must rest upon them. Xovcrtheless, mercury continued to be
<>iven all along-, and more largely as the constitution was found
more reluctant to accept its influence, and more largely still as
other remedies seemed losing their power. Then, in addition,
to as much calomel, united with opium, as the stomach and
bowels would bear, a drachm of strong mercurial ointment was
rubbed in three or four times a day.

But after long delay, and in our utmost need, salivation
c-ame at last — and with the salivation there came a pause of the
disease. The patient, whom we expected to die yesterday, was
found alive to-day. Had the evil symptoms of yesterday been
augmented in the least degree, he must have died. It seemed
hardly possible ; but they remained just as they were, and he
was alive still. The disease had almost touched upon dissolution,
and there it paused.

But could this mere pause, the patient being yet in such
extremity, be taken for a ground of hope ? Yes ! even for a
strong ground of hope, occurring, as it did, under such circum-
stances, and coincident with salivation. For in these cases, after
another day or another night, or sometimes within twenty- four
hours, amendment began to follow this pause ; amendment, how-
over, which was rather in the patient's own feelings than in our
knowledge. Nevertheless, real amendment. We could not yet
calculate the particulars in which he was better : yet he felt
himself better. He had less nervous alarm, less starting from
sleep, less fear of syncope from accidental movements of the
body to this side or that.

To oil)' observation there was still no change of synqjtoms
immediately referable to the heart. From what we could learn
by our percussing, and listening at and feeling the chest, there
was the same prsecordial dulness, the same exocardial murmur,
the same unequal, feeble, fluttering impulse. But there must
have been some change in the actual conditions of the disease ;
and that change might have amounted to an arrest of the in-
flammatory movement at least, and a stop of further effusion.
We could not tell what it was. The patient had the witness
within his own nervous system, and in his own inward conscious-
ness, that a change had taken place, and for the better. And
we had witness of the same in those sure outward manifestations,

192 CLINICAL MEDICINE. [lECT. XV.

by which the nervous system signified, both waking and sleeping,
that it was more at ease.

Thus from the time that the ptyalism appeared, althougli the
exocardial murmur was still audible in one case for several days,
in another for more than a week, and in another for more than
a fortnight, we began to feel assurance, first that the disease
had come to a pause, and then that the patient was further and
further from death, and nearer and nearer to a state of safety,
And it was pre-eminently the nervous system which began and
continued all along to give us this assurance.

But the nervous system was not only the chief witness, it
had also now become (if I mistake not) the great agent of the
patient's safety and recovery. And, as such, it now demanded
our chief care. We had done with addressing remedies to the
vascular system. Bleeding had had its effect, and mercury was
now happily in the course of its operation. Our business was
to soothe, and tranquillise, and comfort the nervous system.
There was little more to do, but there was need of doino- it
efiectually and well. I recollect, in a particular instance, that
four hours' sleep, procured by the dexterous use of opium,
marked the exact period of the patient's safety, and did the
work of a week in furthering his convalescence. He woke with
the number of his pulse, and the number of his respirations,
greatly reduced, and thenceforth neither of them ever regained
an excessive frequency; and though the exocardial murmur
remained for more than a fortnight afterwards, reparation was
manifestly going on.

Such was the course of treatment and the progress of recovery
in certain cases of pericarditis, where mercury was slow to pro-
cure salivation, but procured it at last. I have endeavoured to
make myself as intelligible as I could in noting the cii'cumstances
which seemed to assign to the difierent remedies tlie shares they
had in the result. And their shares, in my judgment, may be
apportioned thus: — Common antiphlogistic remedies could
mitigate, could retard, covdd do all but efiectually stop the in-
flammation of the pericardium, and set reparation fairly at work.
Mercury took up the cure where common antiphlogistic remedies
had left it, and came in with its peculiar power and efiicacy to
complete what they were not able to accomplish. And then
inflammation ceased, and reparation began.

LECT. XV.] MERCURY IN CARDIAC RHEUMATISM. 193

I confidently believe that in every one of these cases death
would have taken place at an early period, and lonj^ before
salivation arrived, had not common antiphlogistic remedies been
opportimely and vigorously employed. And I as confidently
believe that, in every one of these cases, death would have taken
place at a later period, had not the remedial power of mer-
cury been still in reserve, and had not salivation arrived at last.
If we would fairly represent the power of any remedy, we
should not merely point to its more striking effect in a few
cases, but should be at the pains to exhibit truly its ordinary
operation in the majority of cases which occur. On this account,
I have dwelt the longer upon the operation of mercury in those
cases of pericarditis in which it is slow to produce salivation ;
for such, undoubtedly, are the majority.

These, also, are the cases which seem to me to contain
the surest proof of its remedial power. Not that then its
remedial power is the greatest, but that from circumstances it
can then be more clearly seen to be remedial; for they show
both how far the cure can be advanced by common antiphlogistic
remedies, and how much further it can be carried by the help
of mercury.

These, moreover, are the cases in which foreign and English
practice in the management of pericarditis may be fairly brought
into comparison, and in which it may be seen where and how
the one so often fails, and the other is so often successful.

In foreign practice no mercury is used from first to last, but
all the power of common antiphlogistic remedies is brought to
bear upon the disease ; and thus its symptoms are mitigated or
subdued : yet they return again and again, and are again and
again mitigated or subdued. And so the patients are kept alive
for a week or ten days, and then they die in the great majority
of cases.

In English practice mercury is given from first to last. But
it is for a long time as if it were not given at all, for it produces
no sensible effect. Common antiphlogistic remedies, however,
are able again and again to mitigate and subdue symptoms;
and so at the end of a week or ten days the patients are still
alive. Yet they are ready to die ; but in the great majority of
cases they do not die. Salivation arrives late and seems to
save them.

13

194 CLINICAL MEDICINE. [lECT. XVI.

LECTURE XVI.

OF ENDOCARDITIS, INDEPENDENT OF RHEUMATISM. — THE CLINICAL
KNOWLEDGE OF ENDOCARDITIS ALTOGETHER A NEW KNOW-
LEDGE, THE WAY IN WHICH IT WAS OBTAINED SUGGESTS THE

WAY IN WHICH IT MAY POSSIBLY BE ENLARGED. — CASE OF
ACUTE ENDOCARDITIS INGRAFTED UPON CHRONIC VAIA'ULAR
DISEASE. — CASES OF ACUTE ENDOCARDITIS COMBINED WITH

PERICARDITIS IN A PREVIOUSLY SOUND HEART. CASE OF

SUSPECTED ENDOCARDITIS UNDER A MORE CHRONIC FORM.

GENERAL REMARKS.

A FEW years ago, acute endocarditis was a disease almost
unknown ; yet, in fact, it must have been just as frequent a
disease formerly as it is now. Where^ then, lay the secret of
our former ignorance and of our present knowledge ? * Let us
try to trace it out ; and in so doing, we shall see what time,
what instruments, and what happy opportunities, are all needed
to perfect the diagnosis of an internal disease.

Morbid anatomy failed to find it out ; because morbid
anatomy had not opportunities sufl&cient of investigating it.
People rarely die of endocarditis, while the characters of an
acute inflammation are yet traceable in the heart. Before they
die, these are commonly obliterated, and there remain puckerings
and thickenings of the membrane, which are, in truth, the
marks, not of the disease, but of its imperfect reparation.

Clinical observation passed it by ; because clinical observa-
tion had not yet learned the use of auscultatory signs in
reference to the heart. And when their use was generally
understood, it was still the work of much time, and the labour
of many minds, to simplify their application, and to understand
how a single sign, denoting only one thing absolutely, is in-
volved in several diseases, and helps us to discriminate them ;
how the endocardial murmur especially, which only implies

LECT.XVl] ENDOCARDITIS INDEPENDENT OF RHEUMATISM 195

mechanical injury done to the endocardium, helps us to deter-
mine that this injury is in one case the effect of by-gone disease,
or slow disorganisation, and in another the product of present
and progressive inflammation. Now it is the force of concomi-
tant circumstances which stamps their peculiar diagnostic value
upon auscultatory signs. And these circumstances clinical
observation had still to study, long after it knew the signs
themselves, and understood their primary import. The endo-
cardial murmur it had known, and its primary imj)ort it had
well understood for years before it reached the sure diagnosis
of endocarditis, and was made aware of how imjjortant a place
it occupies among diseases. It was the study of concomitant
circumstances which, in this great instance, both perfected our
diagnosis, and enlarged the sphere of our pathological knowledge.

Acute endocarditis may, hereafter, turn out to be of still
more frequent occurrence than it is at present known to be.
Future clinical experience may find it in frequent alliance with
other forms of disease besides rheumatism ; and so, teaching us
under what circumstances to expect it, may set us on searching
for it, and thus may prevent us from overlooking it when it
really exists. The facts for clinical observation to fix upon as
evidence of acute endocarditis are these : First, an audible
endocardial murmur recently declared ; secondly, the coincidence
of its origin in point of time with such general vascular action
as is deemed inflammatory. For my own part, I have, at present,
no familiar knowledge of the conditions indicated, except in
cases of acute rheumatism.

I have seen, indeed, acute endocarditis when it has not been
in alliance with rheumatism, but neither so often, nor under
circimistances so marked, as to gain much instruction by
seeing it.

In the following case, endocarditis was concealed under a vast
complication of disease. The patient was under my care and
observation for a week, yet in the mean time I had not the
skill to discern it. It was unfolded by dissection after her death.

December 19, 1837, Harriet Platford, aged 14, came into
St. Bartholomew's to die. Her lips were livid, her lower
extremities (Edematous, her pulse small, frequent, feeble, and
irregular. She groaned, she coughed, and she gasped for breath.
Auscultation found sibilus and crepitation proceeding from every

196 CLINICAL MEDICINE. [lECT. XVL

part of both lungs, but tiie wbole chest resonant to percussion.
This indicated a diffused bronchitis. It found also an endocar-
dial murmur accompanying the systole of the heart, which was
heard chiefly at the apex. This indicated disease at the mitral
orifice. The heart's impulse was greatly increased.

This poor girl, young as she was, was a servant of all work
in a humble family, l^o distinct history could be obtained
from her of the origin and progress of her complaint. She had
been long ill. It was only during the last three weeks that her
legs had begun to swell, and cough and dyspnoea had become
severely oppressive.

She was kept alive a week. Diuretics were administered.
Very small quantities of blood (two ounces) were thrice drawn
by cupping from below the scapulae, and a blister was aj)plied
to the sternum ; while she was upheld in the mean time by small
quantities of wine. One day she gained a little relief, and lost
it the next. She rallied and sank, and rallied and sank again.
At length the ear caught no sound, either healthy or morbid,
during respiration. All was dull to percussion. She became
more and more livid, was insensible, was convulsed, and died.

Dissection found all that was expected, and something more.
All organs were congested with blood. The liver was large
and dark. The kidneys had their pelvis and tubular structure
stained of a deep red. The mucous lining of the larynx, and
trachea, and bronchi, were deeply livid. The lungs were
gorged. The cavity of the abdomen contained two pints, and
each cavity of the pleura one pint, of yellow serum. The peri-
cardium was distended with serum ; and the endocardium of
both sides of the heart was of a deep red colour. The mitral
orifice would scarcely admit the passage of one finger, and one
process of the mitral valve and the chordae tendineae springing
from it were ossified. Added to all this, the lining membrane
of the left auricle, near its opening into the ventricle, was
covered with little granules and beads of lymph, and the same
were found upon the mitral valve. — W. 24, 68.*

These last appearances contain the evidence of acute inflam-
mation of the endocardium. Yet, in the present state of our
knowledge, no human sagacity could have divined its existence

* The state of tlie cavities and the muscular structure of the heart is
unaccountably left unnoticed in the record of the dissection.

LECT.XVl] ENDOCARDITIS INDEPENDENT OF RTTEUMATISM 1^7

during tlio life of the patient. It probably arose not many
days before death. But its own distinctive murmur Avas merged
in the murmur already existing, and derived from the ossifica-
tion of the mitral valve.

The case, however, was worth relating in some detail, only
to show, under what pathological conditions, besides those of
acute rheumatism, endocarditis may occur.

It appears, then, that acute inflammation may be ingrafted
upon previously existing chronic disease of the endocardium,
and that it may arise during the last days of existence, when
the vascular system is especially disturbed, and blood is
obstructed and retarded in its passage through the lungs and
through the heart.

The next case is made up partly of what was communicated
to me, and partly of what I myself observed. From what I
understood of the nature of the first attack, and the condition
in which I found the heart on auscultation a month afterwards,
I have no doubt that the disease was acute inflammation of the
endocardium, which had its origin in cold and fatigue, operating
upon an enfeebled body.

"A. C, set. 18, had the nettle-rash at Eton about three
months ago. He came to London on its partial subsidence, and
being very weak, was ordered a course of steel medicines, which
he took for five or six weeks. But he still continued weak,
and unable to ride on horseback, or take other active exercise,
to which he had been accustomed. Four weeks ago he witnessed
a cricket match, and stayed on the ground after sunset, and
suffered a chill. I saw him on the 29th of August. Tongue
furred, pulse 108, rigors, pain in the legs, stiffness down the
back, and a very slight pain at the cartilages of the lower ribs
on the left side. Leeches removed this pain, and he was ordered
calomel and James' powder and salines. On the third day of
my attendance, he was much worse. The pulse rose to 135,
and the heart beat with great vehemence. He was bled by
vena3section to 30 ounces, and afterwards had leeches every
other day to the cardiac region. He was also cupped, and was
brought under the influence of mercury, and had three or four
blisters."*

* Thus far the report of the case was furnished me by Mr. Woakes, of
Luton, Bedfordshire.

198 CLINICAL MEDICINE. [lECT. XVI.

The daily progress of his convalescence is not detailed in
the report, which goes on to say, — " For the last six days the
patient's condition has been stationary ; pulse 98, heart's action
heard to a great extent, but hellows-miirmur much less than it
was. He had never had rheumatism, or palpitation, or any
disease of the heart before."

It will be observed that the "bellows-murmur," the sign
most expressly characteristic of the supposed disease, is not
noticed until a very late period. This must have been an
omission from inadvertence. For when mentioned, it is so as
to imply that it had existed for some time previously.

The patient was brought to town on the 27th of September,
for my advice and opinion upon the state of his disease. He
had a peculiar aspect of distress. His complexion was pale,
with a slight flush. His breathing was hurried, and the more
so upon the slightest movement. His pulse was very feeble,
and very small, and frequent. He had some small purpurous
spots on one leg, just above the instep. The lower half of the
precordial region was dull to percussion, and the impulse of
the heart was felt far beyond the apex. Being examined in
the erect posture, a loud endocardial murmur was heard in.
every part of the pra3Cordial region, equally at the apex and
the base of the heart. At the base the murmur became double,
and it was continued, with hardly any abatement of its inten-
sity, along the subclavians and carotids. Being examined in
the supine posture, the murmur, as such, was lost to the ear,
both in the heart and in the blood-vessels, but still a sound was
audible in both, which was different from the natural and
healthy sound. The left side of the chest was altogether reso-
nant to percussion, except, as before remarked, in a certain
portion of the prsecordial region ; and a healthy respiratory
murmur was given out by every part of the left lung. But
the right side was dull to percussion all round, below the level
of the angle of the scapula and of the mamma ; and it was
doubtful whether, throughout this space, there was any audible
respiratory murmur. He lay best on the right side.

At the time I saw the patient, and made this examination,
a month had just elapsed since the first attack. What I found
gave sufiicient evidence of injury done to the mitral and aortic
valves, and of fluid effused into the cavity of the right pleura.

LECT.XVl] ENDOCAEDITIS INDEPENDENT OF RHEUMATISM 199

From a certain jerk accompanying the systole of the ventricles,
I suspected, moreover, adhesion of the pericardium.

Five months afterwards, in the following February, he was
brought to town, and placed under my care. His body was
extensively anasarcous, and the cavity of the abdomen and of
each pleura contained some fluid. He was deeply jaundiced.
His liver was felt lower than the navel, and reaching across
the abdomen from the right to the left hypochondriiim. His
jugular veins were full and prominent, and the whole venous
system was loaded with blood. The great force and extent of
the heart's impulse, and the large space of proecordial dulness,
sufficiently declared the left ventricle in a state of hypertrophy ;
and a loud endocardial murmur audible every where in the
preecordial region, and beyond it in front of the chest, while it
was carried along the aorta and the carotids, left no doubt of
valvular injury both at the aortic and the mitral orifices.

By medical treatment the anasarca was dissipated, and the
chest and the abdomen were emptied of the fluid, which they
contained, and the liver was reduced in size, so that it could no
longer be felt. This was the work of three weeks ; and thus he
was set free from the more formidable consequences of his disease.
But the disease itself remained within its original seat, the heart.
And in three weeks more he was dead. The heart by the simple
vehemence of its action had (as it seemed) the power to kill
him. Air passed uninterruptedly through every part of his
lungs, yet the dyspnoea he sufiered was constant, and it became
an agony on the least movement. His head was racked with
continual pain. He was almost without sleep. He became
delirious, and then maniacal, and then convulsed, and^ at last
sank from exhaustion of his nervous system.

The case, however, after all, must be left incomplete : per-
mission was not granted to examine the body after death, and
thus the best proof was wanting of what the disease of the heart
really was ; yet, even with this defect, the case deserves to be
recorded. For it can hardly be doubted that the disease was
acute endocarditis, and it is most probable that pericarditis was
conjoined with it from the first. The period of its origin was
well ascertained. It sprang from one of the common causes of
inflammation, and it was unconnected with rheumatism.

Dr. West, from his large experience of the diseases of chil-

200 CLINICAL MEDICINE. [leCT. XVI.

dren, has contributed some cases of idiopathic endocarditis.
One of them is quite to our present purpose, and I shall quote it.

"Daniel Bain, aged 11 years, living at No. 37, Thomas
Street, Stamford Street, is one of 12 children of healthy parents.
Nine children are still living, one died while teething, one of
scarlatina, and one of pneumonia. There does not appear to be
any phthisical taint in the family.

"Daniel has had good health, with the exception of mild
attacks of measles, hooping-cough, and scarlet fever ; and was
as well as usual until May 8, 1843, when he complained of
feeling cold, and began to cough. The chilliness was succeeded
by fever, and he continued gradually getting worse till the 13th,
when I visited him for the first time. He had had no other
medicine than a purgative powder.

" May 13. — I found him lying in bed ; face dusky, rather
anxious ; eyes heavy ; respiration slightly accelerated ; frequent
short cough without expectoration ; skin burning hot ; pulse
frequent and hard. The child makes no complaint, except of
slight uneasiness about the left breast.

" There is slight tenderness on pressure over the heart, with
very extended dulness. The heart's impulse is not increased.
A very loud and prolonged rasping sound is heard in the place
of the first sound ; it is loudest a little below the nipple, though
very audible over the whole left side of the chest, and also dis-
tinguishable, though less clearly, for a considerable distance to
the right of the sternum. Second sound heard clearly just
over the aortic valves, not distinct elsewhere, being obscured by
the loudness of the bruit.

" Respiration good in both lungs.

"I ordered the child to be cupped to |vj. between the left
scapula and the spine ; and gave gr. j. of calomel, with the
same quantity of Dover's powder, every four hours.

" 3Iay 14. — Sense of discomfort at the chest relieved by the
cupping. He slept well during the night, and to-day looks less
anxious, though his eyes are still heavy and suffused ; the skin
is less hot and less dusky; pidse 114, thrilling, but not fuU;
tongue moister than yesterday, red in the centre, coated with
yellow fur at the edges ; has had one copious watery evacuation ;
slight prominence of the cardiac region. The heart's sounds
are obscurer and more distant than yesterday ; the bruit of yes-

LECT.XVl] ENDOCARDITIS INDEPENDENT OF KlIEUMATLSM. 201

terday is now manifestly a friction sound, whicli is louder at the
base than at the apex of the heart ; the first sound is altogether
obscured by it, and the second is heard only over the aortic
Talves.

" The child has had four powders. To continue taking-
them every six hours, 3J. of strong mercurial ointment to be
rubbed into the thighs every six hours. Six leeches to be
applied over the heart.

" May 15. — There was considerable difficulty in stopping the
bleeding from the leech-bites, which was so profuse as to make
him rather faint. He slept tolerably during the night, and
imtil 6 A.M., when he became light-headed, and continued so
until 9 o'clock this morning, but has since lain quiet, though
troubled by a dry cough.

" His appearance is much as yesterday ; skin dry and hot ;
pulse 120, possessing the same character as before, but with
less power ; tongue coated at the edges, with a dry red streak
in the centre ; bowels open twice, motions green and watery.

" Auscultation yields the same results as yesterday. Same
treatment continued, with the addition of a saline draught
containing small doses of the liquor antimonialis every four
hours.

" May 16. — General condition much as yesterday, but on
the whole seems slightly improved ; pulse 120, softer.

" The friction sound is no longer audible, but a loud rasping
sound is heard in the place of the ^first sound. The second
sound can now be distinguished at the apex of the heart as well
as over the aortic valves, and is quite natural.

" On the 17th, the gums were slightly aifected by mercury
and the bruit was thought to be softer and rather less loud.
The dose of calomel was now reduced to gr. ss. every four hours,
and the child was allowed a little broth.

" On the 22nd his mouth was very sore, and all active treat-
ment was discontinued on that day. The child gradually re-
gained his strength, but the bruit accompanying the first sound
continued, and was heard a month afterwards with no other
change than being rather softer and more prolonged."*

In how many prominent circumstances does this instance of
idiopathic endocarditis run parallel to the course of endocarditis
* Med. Gaz. vol. xxxii. p. 738. An important paper.

202 CLINICAL MEDICINE. [lECT. XVI.

in numerous instances connected with acute rlieumatism ! Its
accession is quickly followed by the accession of pericarditis,
then both proceed together for a few days ; then the exocardial
murmur which belongs to the latter ceases, marking the per-
manent adhesion of the pericardium. But the endocardial
murmur which belongs to the former remains and continues
alone, and still abides, after the boy has recovered his health
and strength, marking a permanent injury of the valves.

While, therefore, at present our chief knowledge of endo-
carditis is as an accompaniment of rheumatism, yet, whenever
we catch a glimpse of it under other conditions, we recognise
it as in itself pathologically the same, affecting the same course,
admitting the same coitiplications, needing the same remedies,
and leading to the same events.

The following could surely be no other than a case of endo-
carditis. What neither its history nor its symptoms could clearly
show, was sufficiently denoted by the nature of the treatment
which effected its cure.

H. B., set. 43, presented himself to me one morning, with a
countenance full and florid, and complained of a pain and sense
of weight and tightness between mamma and mamma, occupying
a space large enough to require the whole hand to cover it. The
pain, he said, was not constant, but was more on than off. It
had thus endured between two and three months, and was cer-
tainly upon the increase. Lately some dyspnoea had been added
to it. The dyspnosa, but not the pain, was augmented by exer-
tion. His pulse was 80, and regular, without any peculiar
character of hardness or fulness.

Auscultation found a perfectly healthy respiration ; but a
very loud systolic endocardial murmur at the apex of the heart.
On this occasion, he, being very hot and perspiring, was ex-
amined through his shirt and flannel waistcoat. The man was
a collector of taxes. He had never known illness before. He
was habitually a full liver, eating abundance of animal food,
and drinking plenty of beer and porter.

In this case I had no other thought than that the murmur
proceeded from some tardy conversion of a portion of the
mitral valve into cartilage or bone, which by its gradual
increase had now reached a point at which the heart and the
circulation must begin to feel it, and must ever continue to feel

LECT.XVl] ENDOCARDITIS INDEPENDENT OF lillEUMATISM 203

it, painfully and injuriously. I could not, however, tell how
long the murmur had existed, and so, for the sake of creating
a little hope for myself in the management of the case, I was
willing to believe that it might not have existed earlier than
the date the patient gave of his own uneasiness, and that it
might then have arisen from, and might still be due to, some
active process of disease within the reach of a remedy ; and I
set about its treatment accordingly.

I ordered ten leeches to the prsecordial region, and some
active aperient medicine ; and I enjoined a rigid abstinence
from all wines and fermented drinks, and perfect rest at home.
Three days afterwards, he spoke of a general sense of relief ;
but said the pain was more abated than the dyspnoea. I now
made a more accurate auscultation of the bare chest, and found
the murmur less loud. It accompanied the systole, and the
limit within which it was heard included about an inch and a
half of the praecordial region, viz. the mamma, and a little
space on the sternal side of it and below it. There was dulness
to percussion at the apex, and for a couple of inches lower
down. There was no perceptible increase of impulse. The
murmur^ which was manifestly less while he remained still, be-
came as loud as ever after he had walked twice across the room.

I ordered ten more leeches to the proecordial region, and
two grains of calomel every six hours.

In three days more the murmur had certainly still decreased ;
there was no salivation ; he was ordered to continue the calomel.

In seven days more, he was fairly salivated, and had been
so five days ; I was not certain of any murmur ; the sounds of
the heart were loudly intonated, but it was doubtful whether
they were really -unnatural. I wished the salivation to be still
maintained by two grains of calomel taken every night.

In seven days more, upon a very patient auscultation I
satisfied myself that there was still just that degree of pro-
longation, and that slight roughness of the first sound which
one hears before the murmur is decidedly audible in acute
rheumatism. Exertion brought out the real murmur, but it
was very faint ; no dulness to percussion remained in the
situation first indicated.

KSalivation to be maintained.

In seven days more, I foimd that since I last saw him he

204 CLINICAL MEDICINE. [lECT. XVI.

had been following the same plan of treatment, except that he
had not observed perfect rest ; he had walked about as usual
in his business, but had been careful to avoid all hurry ; he
spoke of a sensation about his heart ; it was not pain ; he could
not tell what it was, or whether it was without or within ; it
was something which did not naturally belong to him ; it was
not always present, nor was it increased by exertion ; but there
was something which he could only call a sensation. After very
attentively examining him, and making him walk rapidly about
my room, my ear coidd detect no murmur, or any other un-
natural sound accompanying the movements of the heart.

If I have rightly interpreted the nature of this case, here
was endocarditis arising and existing as the whole and sole
disease, unaccompanied by rheumatism or by any other known
malady elsewhere in the body. At all events, here was a
formidable group of symptoms, all referable to the heart, and
all gradually disapjiearing, and the murmur among the rest
under the use of remedies addressed to the purpose of arresting
inflammation.

This case teaches a practical lesson of some value. It is this
— that we should be slow in reckoning diseases to be incurable.
The murmur was not known to have its origin in inflammation
of the endocardium, but was found among other symptoms
referable to the heart, which had existed between two and three
months. Yet both it and they were successfully treated, and
ceased. This instance, therefore, gives us encouragement to
hope sometimes beyond what we know, and to direct our treat-
ment accordingly. Where palpitation, dyspnoea, and precordial
pain, of no very remote duration, are found in alliance with
the endocardial murmur, we should make the most of it, as an
indication of treatment, in the hope that the whole disease may
depend upon a covert and slowly progressive, but remediable
endocarditis.

There is no part of pathology which calls for the more
earnest regard of medical men than the diseases of the endo-
cardium, especially with a view of making out what they are
in their first formation, and noting, with clear marks of dis-
tinction, those which are simply inflammator}^, and come within
the possibility and promise of cure.

Of how many cases of complex disorganisation of the heart,

LECT.XVl] ENDOCARDITIS INDEPENDENT OF RHEUMATISM 205

already gone far beyond the possibility of reparation, does
valvular disease form a part ! In tbe vast majority of these,
there is reason to believe that the valvular disease was the
original and elementary change of structure to which all the
rest was superadded as a natural and necessary consequence,
and that there was a time when it existed singly and alone,
without either the dilatation of the cavities, or the hypertrophy
of the muscular substance, or whatever else may make up the
complex disease which is at length found.

Well, then, it is this valvular disease that we want to
know more about. In many instances it can be traced back to
an attack of acute rheumatism, when the endocardium was
inflamed. But in many more acute rheumatism forms no part
of the history. What, in such instances, is the nature of this
valvular disease, or rather what icas it from the first ? It is too
discouraging a view of the matter to regard all valvular dis-
ease, which is not traceable to an attack of acute rheumatism,
as essentially chronic and irremediable from the beginning, and
so give up further inquiry in despair.

Remember, it is not long since this district of pathology to
which I am pointing, was utterly dark. It is but lately that
clinical research has thrown light enough upon it to show that
there is such a thing as inflammation of the endocardium ; acute,
rapid, lymph-depositing inflammation : inflammation in its
nature curable ; and, when perfectly cured, allowing the mem-
brane to recover its integrity as if it had been never diseased ; and
when imperfectly cured, spoiling a valve, and leaving it to become
a point of departure, from which the heart may proceed to any
mode or extent of disorganisation which it is cajDable of. But
(I repeat) it is in alliance with rheumatism that all, or nearly
all, which we thus know of endocarditis has been learnt and
authenticated. A glimpse, indeed, has been caught of it apart
from rheumatism, enough to show that it may exist, but not
enough to familiarise us with it under other conditions ; not
enough to bring those conditions distinctly into view, to enable
us to say what they are, and to know from them when to expect
it, and be prepared to treat it.

It would be well for those who feel strongly the desirable-
ness of more knowledge upon this subject, to consider how it is
most likely to be obtained. Now I see little to hope from any

206 CLINICAL MEDICINE. [lECT. XVI.

more curious scrutiny of auscultatory signs, or from any further
poring and pondering over symptoms immediately referable to
the heart itself (the heart itself already speaks plainly enough
about its diseases, if that were all) ; but I look with better
promise to clinical research among fevers and febrile ailments
of the constitution at large. For it was by the light first let
in from thence, that the discovery was made within our own
time of some of the most important diseases to which particular
organs are liable. These diseases had for ages remained occult ;
and they were so because, during the period of their greatest
activity, they are wont to put forth no symptoms calculated to
arrest attention. But now that the diseases themselves are
known, their symptoms are found to be sufficiently definite.
They are, however, such as require to be sought after before
they are found. But whence do we get our hint to search after
them ? Even from the more general and more apparent con-
ditions of disease with which experience has found them
naturally associated. Thus having typhus fever to deal with,
we seek for follicular ulceration of the intestines, and often find
it. Having scarlet fever, we seek for inflammation of the
kidneys, and often find it. Having acute rheumatism, we seek
for endocarditis, and often find it. It was, indeed, a great
thing — a thing to be valued at the worth of many lives — to
find out these natural alliances of ulceration of the intestines,
inflammation of the kidneys, and endocarditis, with those seve-
ral more prominent and obvious conditions of disease in the
constitution at large.

But, doubtless, each of these several diseases of particular
organs occurs unallied with any such fevers of well-known
type and character. How often, I cannot tell ; probably much
oftener than any one suspects. As to endocarditis, we have lit
upon it a few times by accident, obscured by circumstances,
but at an early and curable stage, when it would probably have
been cured, had it been more clearly seen, and had it presented
a steadier mark for the aim and direction of medical treatment.
And, times without number, we have met with chronic valvular
disorganisations which might have, and probably had, their
origin in some attack of endocarditis, which was never known,
and never treated.

But som etimes to light upon it by accident, and oftentimes

LECT.XVl] ENDOCARDITIS INDEPENDENT OF RHEUMATISM 207

to be hopelessly admonisliecl by its fatal consequences that it
has existed, would seem to imply that clinical observation has
yet much to search after, and (it is hoped) has yet much to
find, respecting the origin and progress, and various pathological
relations of endocarditis.

Of what endless and still increasing necessity is this business
of clinical observation to the improvement of our art ! ! All
that has been found out by those who have gone before us does
not leave less, but more to be sought after by ourselves. Each
new fact is a mere curiosity, while its value and its uses are
yet undetermined. Labour or chance may have first disclosed
it, but its value and its uses can only be ascertained by long
observation and experience. For, until it be seen, how other
facts, already known, naturally group themselves around it, we
can understand neither its place nor its bearing in the system
of things to which it belongs. In this way does each newly
discovered fact suggest and multiply new inquiry ; and thus
there are never wanting to our profession fit objects for the
best understandings to pursue.

Clinical observation, with a view of keej)ing a man up to
what is known, and perfecting him in its accustomed uses, may
be an affair of sober industry only, of patient and almost
passive looking on. But clinical observation, with a view of
knowing more than is known, and turning new knowledge to
its uses, belongs to an industry of another kind, to an energy
ever active and stirring, and drawing upon, and working with,
the highest faculties of the mind.

208 CLINICAL MEDICINE. [lECT. XVII.

LECTUEE XYII.

PERICARDITIS INDEPENDENT OP RHEUMATISM. — SHOWN BY MORBID
ANATOMY TO BE OF COMMON OCCURRENCE. — ITS SMALLER

DEGREES THE MOST FREQUENT. PROBABLY HARMLESS.

GENERALLY BEYOND THE REACH OF CLINICAL DIAGNOSIS,

ITS GREATER DEGREES NOT BEYOND ITS REACH, BUT APT TO

ELUDE IT. ^WHY. COVERT ACUTE PERICARDITIS AND COVEBT

ACUTE PLEURISY COMPARED. REVIEW OF CASES WITH THE

PURPOSE OF FINDING WHAT NATURAL ALLIANCE PERICARDITIS
MAY HAVE WITH OTHER GENERAL PATHOLOGICAL CONDITIONS
BESIDES RHEUMATISM.

There is no structure of the body more liable to inflammation
than the pericardium. Of those who have reached adult age
and upwards, one half (it appears) have suffered pericarditis at
some period of their existence. But then, in the vast majority
of cases, it is neither detected, nor perhaps detectible, during
life. It comes and goes unnoticed, and neither by itself while
it remains, nor by its efiects when it has ceased, does it do any
amount of injury capable of interfering with the healthy
actions of the heart. Hence in five cases out of six there is no
clinical history to be given of pericarditis. How and when,
and under what circumstances it takes place in the living man,
we have not the smallest experience. All our knowledge of it
is from its effects which we discover in the corpse.

All those white spots upon the surface of the heart, which
have engaged and perplexed the speculation of pathologists
ever since they have betaken themselves to dissection, have at
length been demonstrably shown by Mr. Paget to be the effects
of inflammation. To show the absolute frequency of pericar-
ditis, and the comparative frequency of the slighter and severer
cases, Mr. Paget gives the following summary of his dissec-
tions:— "Including these white spots among the efiects of
pericarditis, I find that, of 110 cases which I have lately

LECT.XVIl] rERICAKDITIS INDEPENDENT 01'^ JillElJ^LVTISM 200

examined iit St. Bartholomew's Tlospital, 58 have presented
signs of having- sulfcred at sonic time from that disease. Among
these, 40 out of 66 males, and 18 out of 44 females were thus
affected; and, with respect to their ages, the morbid appear-
ances were found in 5 out of 14 below twenty; in 25 out of 53
between the ages of twenty and forty; and in 28 out of 43
above forty. Of these 58 cases of pericarditis, 49 were slight
cases marked by white spots and adhesions, or by ell'usions of
small quantities of lymph ; and nine were severe, with complete
adhesion, or with abundant recent effusion."*

But in the slighter cases of pericarditis, though neither
pain nor any disturbed action has ever led to a surmise of its
existence, yet is it not prob'vble that the inflammation, while it
was in the act of depositing the Ij^mph which formed the while
spots and the small adhesions, gave occasion to the genuine to
and fro sound? Indeed, it is most probable. But what,
though the sound were there, if it was not heard ? And heard
it could not be, if it was never listened for. And, unless
attention were expressly drawn to the heart by its disturbed
action, or the patient's reference of pain to it, no one would
think of listening for it.

Surely, then, the reasons are plain enough why the lesser
and most frequent cases of pericarditis have hitherto altogether
eluded observation during life. And, until they are brought
within the reach of our clinical knowledge, they cannot become
the objects of our medical treatment.

Doubtless it w^ould be to our credit, that pericarditis in all
its slighter degrees should come within our knowledge and
treatment. But, because this is not the case, mankind has
suffered nothing. For such pericarditis is harmless from
beginning to end. It puts life to no present peril, and does no
ultimate injury by its effects. These white spots and slender
adhesions of the pericardium are often found where there is not
a vestio-e of disease besides; and then the heart at the same
time is so constantly found perfect in size, and form, and
capacity, that they may be considered as things almost purely
innocent.

What I am now saying of the pericardium and its covert
inflammation ending in white spots and small adhesions, wjiU
* Med. Chir. Trans, vol. xxiii. p. 29.

14

210 CLINICAL MEDICIXE. [lECT. XVII.

call to niiud what, in a former lecture, I said of the endocar-
dium and its covert inflammation, which ended in puckering,
tliiciccning, and shortening of the valves.

But the inflammation of the tvro structures, while they are
(both alike in the secrecy with which they caiiy on their
elementary process, arc most unlike ever afterwards. While
email patches of lymph and small adhesions of the pericardium
are never felt injuriously — indeed, are not felt at all — a spoiled
valve (and how little does it take to spoil it!) at once begins
to baffle the functions, and ends by disorganising the entire
structure of the heart. To the clinical study of the two
diseases we are urged by very unequal motives, inasmuch as
with respect to the one mankind suffers not at all, but with
respect to the other it suffers to a great amount, from the dark-
ness in which both are often involved in their beginning and
progress during life.

I do not see how it is possible, but that pericarditis and
endocarditis in their slighter degrees must ever continue to
escape our notice, until they are found to have some constant
or very frequent alliance with other forms of disease bej'ond
the heart, which are better knoAvn and more familiar to our
experience than they are themselves.

It is jJrobable that the attack of inflammation, leaving such
permanent effects upon the pericardium as have been described,
often takes place during some fevers. Doubtless during the
progress of fevers, inflammation of small degree and small
extent is apt to arise and to continue for a Avhile, and then to
cease without any special remedy, or any treatment more than
is included in the general management of the fever. I recollect
in a case of typhus fever, about the middle of its course, a loud
friction-sound being heard in the preecordial region. It con-
tinued distinctly audible for three days, and then ceased
altogether.— (M. xxxi. 85.)

i)ut the very numerous cases in question which have but
lately been shown to be of the nature of inflammation, or even
to partake of the character of disease at all, these slighter cases
of pericarditis, stand quite alone, and offer very little promise
. of being better understood clinically than they are at present.
Wo will leave them, therefore, and turn to others of greater
interest.

I-ECT.XVIl] PERICARDITIS INDEPENDENT OF RHEUMATISM 211

Pericarditis, it is well known, may occur in its acutest form,
and yet bo unconnected with acute rheumatism. Our clinical
acquaintance with it as such is indeed less perfect; and on that
very account, perhaps, it is the more dangerous. For our
clinical acquaintance with it will appear to be less perfect
chiefly in this respect, that we have no exact knowledge of the
circumstances conducing to it. And this is quite enough to
make us less alert in detecting it, and less ready with our
I'cmedios in treating it.

Associated with this disease, there are certain recollections
of things which made a great impression upon my mind when
I first betook myself to the study of physic, and which I now
feel it interesting and profitable to recal.

It was then a sort of transition period in medicine. Men
were pushing their research in a new direction, but had not
yet arrived at many sure results. They were inquisitive espe-
cially into what might remain of the vestiges of disease after
death, as offering a promise of larger and more accurate know-
ledge.

In this new zeal for dissection, a vast deal of rough morbid
anatomy was practised, teaching many new facts which led to
some truth and to much error, the natural fruit of over-hasty
conclusions.

Now, it was a long time before I could appreciate in the
least degree the more important uses of the facts which dissec-
tion was daily disclosing to me. But there was one thing
which I was not slow in finding out from morbid anatomy, viz.
the great imperfection of the diagnostic part of medicine. That
many forms of chronic disease should be often found after
death, which had not been suspected to exist during life, was
no surprise to me. This is what might have been expected.
But I v/as indeed astonished that it could ever hapj^en (as
happen it frequently did), that patients who had been carefully
watched day by day, should, when they came to die, be found
to have perished of acute destructive inflammation of some
vital organ, which had never been suspected to exist while they
were alive.

It was the chest which was most frequently the seat of this
acute, covert, and mortal disease ; and of the parts within the
chest, most frequently the pleura or the pericardium. To my

212 CLINICAL MEDICINE. [lECT. XVII.

amazement, the pleura or the pericardium were occasionally
found covered with recent lymph, and their cavity full of turbid
purulent fluid, where during life there had been neither thought
nor mention nor treatment of pleurisy or pericarditis.

The students were the chief morbid anatomists in those
days, who yet knew nothing of the difficulties of their profes-
sion, and made no allowance for them. To such young, sharp-
sighted, inexperienced lookers-on, these unhappy instances
would minister occasion for ridicule of their betters. They
would pass harsh judgment on the physician, and express
opinions not very complimentary to his sagacity.

But was the fault in the physician, or in the imperfection
of his art? I trust it was in the imperfection of bis art; if it
were not so, I ought to have some painful reflections. For I
confess (and it is my duty to confess) that the experience of
after years, and the best care and watchfulness I could bestow
upon individual cases, did not exempt me, in my turn, from
the occasional mortification of finding upon dissection that a
patient had died of an acute pleurisy, or an acute pericarditis,
which I had never suspected during life; of pleurisy, however,
much oftener than pericarditis. For, as an acute, disorganising,
destructive inflammation, pleurisy is by far the more frequent
of tlie two.

Such painful oversights are now not apt to occur ; not that
physicians in general, or the same individual physicians, were
less sagacious formerly than they are now. There is no room
for disparaging our predecessors and glorifying ourselves, or for
complimenting our present selves at the expense of our former
selves, in this matter. The truth is, a discovery has been made
in the art of clinical observation, and we all have the benefit of
it. Without the aid of auscultation, it is impossible but that
the same diseases should still often go undetected. A few cases
of pleurisy present themselves to me in the course of every
twelvemonth, which, but for the use of my ear, I should detect
either not at all, or not time enough to interfere effectually for
their relief.

But before auscultation was practised, pericarditis (I mean
acute, disorganising, destructive pericarditis) did not go so often
unnot"c3d and untreated as acute pleurisy. Yet there was the
same want of exact pathognomonic signs to designate the one as

LlXT.XVIl] PEIIICARDITIS INDEPENDENT OF RHEUMATISM 213

tlic other. But then, with respect to pericarditis, this most
important fact had already been learnt by experience, that
though its own direct signs were vague and uncertain, it was apt
to be associated with other conditions of disease as plain and
obvious and distinctive as possible, those, namely, which con-
stitute acute rheumatism. Thus, wherever there was acute
rheumatism, wo knew that pericarditis might be ; and we were
sedulously on the watch for it, and ready to take the least pras-
cordial flvitter or pain as an evidence of it, and a warrant for
treating it. We made sure of it from a mere glimpse, and
pointed our remedies at it as if it was clearly in our view.

But when it occurred alone, or among other conditions of
disease, with which it was not known to have any frequent or
natural alliance, it ran a great chance of escaping detection and
treatment ; and it often did eseaipe both, and prove rapidly fatal

And even now, with all the sure signs which auscultation has
unlocked and brought from their hiding-place, it still is apt to
escape detection and treatment, and consequently to prove fatal.
jN^early the whole sum of my experience of acute pericarditis,
independent of rheumatism, is derived from cases in which it has
been concealed during life, some occurring prior and some sub-
sequently to the use of auscultation. In the former it could not
possibly have been detected for want of auscultation ; and in the
latter it lay concealed, because auscultation went for nothing
when the auscultatory signs were not listened for.

I will now produce some specimens of pericarditis, as I have
seen it occur independent of acute rheumatism. The sort of
patients in whom it is found, and its attendant circumstances,
may, perhaps, give some hint of the pathological conditions
conducing to it.

W. B., ffitat. 26, a pale, bloodless, emaciated being, Avas
carried into St. Bartholomew's Hospital, retching and vomiting,
and coughing incessantly ; he had a pale, dry, rough tongue,
without the least secretion upon it ; his pulse was hardly j^er-
ceptible, and all things bespoke him to be at the point of death.
He had been brought to his present condition by an illness of
live weeks. Five weeks ago he had been attacked with j)urging
of blood, and with vomiting or spitting of blood (he could not tell
which), at the same time ; and these hsomorrhages continued, in
some degree, for an entire fortnight.

214 CLINICAL MEDICINE. [lECT. XVII.

He was by trade a journeyman tailor, a class of society
Aviiich has furnislied me with inore cases of profuse haemor-
rhage from the stomach and bowels than any other, and in
which the habit of spirit-drinking is carried to the most horrible
extent.

After his admission the retching and vomiting continued,
but there was no haemorrhage, and the evacuations from his
bowels were natural ; he became delirious ; and in a day or two,
delirium and stupor became his most prominent symptoms;
and what little pulse could be perceived, was irregular. It was
necessary to give him wine ; and sometimes, under its influence,
the pulse would gain a little power, and recover its regularity,
but it would soon lose its power, and then it Avould become
irregular again. A week passed, and he continued to live on,
when er^'sipelas appeared upon his face and neck, and in three
days more he died.

In this case there was no symptom which could possiblv
suggest a suspicion of disease of the heart, except the irregular
pulse. Yet it suggested (I confess) no such suspicion to me ;
I saw in it only the last struggling effort of the heart to keep up
life a little longer. When the pulse became stronger under the
stimulus of wine, it for the time became regular also ; and when,
as the stimulus ceased, it again lost its power, it again became
irregular. All this looked very like failure from simple
weakness.

But, upon dissection, the pericardium was found to contain
several ounces of serum, deej)ly tinged with red, and covered
both on its loose and reflected portions with a very large accu-
mulation of lymph. The lymj^h connected the two oj)posite
surfaces by filamentous bands of soft texture, and was easily
detached. Besides these unlooked-for appearances of the peri-
cardium, the mucous membrane of the stomach was stij^pled
with points of red, and was softer than natural. Throughout
the whole intestinal canal, there was a redness, which seemed
to be something dift'crent from simple injection of the blood-
vessels, and to reside in the submucous cellular tissue. The
peritoneum was pale, and contained within its cavity a consider-
able quantity of clear serum. The brain and its membranes
were exsanguine, while there was much serum beneath the
arachnoid. The lungs Avere sound. — (M. iii. 74.)

ILECr.XVIl] PERICAKDITIS INDEPENDENT OF RHEUM ATISM 215

Hero we had disclosed by dissection the sure effects of acute
disorganising- inflammation of the pericardium ; and tliis it waa
that killed the patient. Yet were there'no general symptoms
notifjdng such inflammation any wliore, and no pain or other
sign immediately referable to the heart, notifying tliat it could
be there, except the almost imperceptible and irregular pulse ;
and this seemed to speak of death rather than of disease.

But this case fell under my observation before any thing
was yet known of the auscultatory signs which mark disease of
the pericardium. Yet had they then been as well nnderstood
«is they are now, I was so entirely without any suspicion of the
heart, that I doubt whether I should have applied my ear to it.

Now I have dwelt more particularly on this case, because it
is one of a class (such, at least, is my impression) to which a
peculiar pathological interest belongs. And it is a good
specimen of that class.

It would hardly be suspected that the very act and process
of dissolution could give occasion to neio disease. Eut such is
the fact. And it happens especially, if the dissolution be slow
and lingering ; and then this new disease is often even of an
acute kind. In no part of the body is this new disease more apt
thus to light up, at the very going out of life, than in serous
membranes. Among phthisical patients, who have been dying
by little and little for many weeks, the instances have been
numerous, in which upon dissection I have found the marks of
very recent peritonitis, the cavity of the abdomen containing a
whey-like fluid, and the surface of the intestines covered with
.flocculent lymph, and streaked with red, and adherent where
their folds lie in contact. Yet in many such cases the peritonitis
has given no notice of its existence during life by its proper
symptoms, and after death has occasioned great surprise by its
discovery. And thus, too, pericarditis will arise Avhcn the
system is at its lowest state of depression. I have known some
instances (and others have been rej)orted to me), where, after
severe accidents and severe surgical operations, the powers ol
life being brought very low, and existence with difficulty main-
tained during some days, upon death eventually taking place,
the pericardium has been found covered with flocculcnt lymph,
.and its cavity distended with serum mixed with pus and blood.
These were the products of the most acute inflammation. But

216 CLINICAL MEDICINE. [lECT. XVII.

the patients were scrupulously watclied during life, yet no
pymiptoms indicative of inflammation were discovered.

A young man of unfavourable constitution suffered from in-
flammation of tlie internal structure of both eyes. He was largely
bled, and brought raj)idly under the influence of mercury.
Great dyspnoea arose Avith the salivation. Both of his lungs and
bis larynx became inflamed. He passed into a state of coma,
and after lingering for a few days he died. Upon dissection,
besides efiusion between the membranes and into the ventricles
of the brain, and ulceration of the larynx, and hepatisation of
the lungs, and a pint of fluid in the left pleura, there was found
upon the surface of the pericardium covering the heart a large
deposition of soft recent lymph, particularly about the origin of
the great blood-vessels, and the muscular substance of the heart
itself pervaded by a white interstitial deposit (apparently lymph)
which was thickest near the pericardial surface. — (M. xx. 56.)

A few instances have occurred within my knoAvledge (^f
individuals having been picked up in the street, and brought
into the hospital in a dying state, who, nevertheless, have sur-
Adved for a few days, and afforded time to investigate the con-
ditions of their disease. Nothing, however, was made out
concerning them, but that they were dying ; and not the least
conjecture could be formed Avhere their disease was, or what it
was. Upon dissection, the pericardium was found covered with
lymph, and its cavity distended by turbid scrum.

I think it worth while to add the folloAving cases, as further
specimens of the conditions under which pericarditis is apt ta
arise, and of its complications. They are cases Avhich contain
many points of great interest.

W. C. was a poor boy, ten years of age, who came into the
hospital to die after an illness Avhich he had already endured
eight months. His Avholc body was ccdematous, and his abdomen
full of fluid. He was very pale ; he was too weak to stand ;
and his pulse was rapid, small, and feeble.

The account given of him was this : — eight months jjreviously
he was seized Avith A'omiting of green matter, and three days
after Avards Avith purging of blood. This latter continued for
several days, and, upon the Avhole, the quantity of blood lost
was A'ery large. The hocmorrhage having ceased never returned ;,
but a few days afterAvards, oedema commenced in the lower

LECT. X VI r] ri:EICAEDITIS INDEPENDENT OF EHEUMATLSM 2 1 7

extremities, and in llie course of a fortnight pervaded, tlic whole
body ; fluid was then accumulated in the cavity of the abdomen.
All medicines failing to give relief, at the expiration of two
months lie was tapped. Hereupon his kidneys began to act
profusely, and in six weeks he Avas entirely free from all dropsical
swelling, and he continued free until within five weeks of his
admission into the hospital; then the dropsical symptoms no
sooner returned, than they increased rapidly, and, in the course
of a fortnight, they reached their extreme amount.

The poor boy seemed dying when he was brought in, yet ho
lived a fortnight. His days and nights were passed in extreme
jactitation and perj)lexity, in delirium, and vomiting, and
struggling for breath. His urine was loaded with albumen,
and auscultation detected fluid in the chest. Three days before
his death, a loud creaking crumpling sound was heard to
aecompany the contractions of the heart. It was audible over
a large part of the chest in front. (The heart had been care-
fully examined before, and its sounds were noted to be " not
unnatural.") The crumpling sound was accompanied by some
increase of impulse ; but in twenty-four hours it ceased to be
audible.

Dissection found the internal collections of fluid, and the
granulated kidneys, and the pale softened textures, which were
anticipated ; and it found withal on the surfaces of the pericar-
dium covering, and opposite to both the auricles, a network of
lymph, in which numerous soft granules were dejDOsited. The
pericardium was unusually vascular throughout, but especially
at the parts from which the lymph was detached. The muscular
substance of the heart, and its internal lining, and that of the
aorta, were unusually red. — (M. xvii. 29.)

Here to accumulated suffering and disease, which probably
first sprang from inflammation of the kidneys, pericarditis was
at length added, and raj^idly brought on death.

In like manner, pericarditis came and closed the scene in
the next case. One opportunity only was afforded for examina-
tion during life, but it was enough to give suspicion that
disease was at work upon the heart, wherever else it might be.

W. G., aitat. 50, was admitted by mistake into the surgeon's
"ward, whence he was presently transferred to me. He was
nearly comatose, and naturally almost deaf. He lay on his

218 CLINICAL MEDICINE. [lECT, XVII.

back witli his muscles quivering, and muttering occasionally to
himself. His left eye was inflamed superficially, liis jugular
veins distended, but without pulsation. His pulse was 72 with
power, and ho flinched from pressure on the epigastric region.
We succeeded in rousing him a little, but could not succeed in
getting any rational expression from him, except to the effect
that he felt no pain.

We could only auscultate his chest as he lay ; that is, in
front ; and found a rhonchus mixed with large crepitation
proceeding generally from the lungs, and a very peculiar
bruit from the heart, which accompanied the systole of the
ventricles.

Hereupon he was cupped upon the pnccordial region.

In twenty-four hours he was dead.

Here, too, upon dissection, tlic kidneys, large, hard, pale,
and mottled, and entirely disorganised by granular disease,
presented themselves as the source of morbid actions, which had
been going on throughout tlie Avhole body for years. On the
left side, the lungs floated in three pints of bloody serum, and
on the right, in two, themselves being gorged with blood. In
the cavity of the peritoneum, two pints of yellow scrum Avere
effused without apparent disease of any abdominal viscus. The
pericardium contained three ounces of serum ; and the membrane
itself, both its loose and reflected portion, was covered with a
fine, reticulated, adventitious membrane of coagulabic lymph,
most abundant over the left cavities. It was easih^ detached,
and left the surface beneath studded with red spots. The heart
was rather large, but well proportioned in all its parts. —
(M. xiii. 39.)

Such are the specimens I have to give of pericarditis, not
in alliance Avith rheumatism. In them all, you will observe it
complicated with disease of other internal parts, and especially
with disease, or the results of disease, of similar structures;
with inflammation, or serous and sanguineous eff'usion, of the
pleura or peritoneum. In short, of pericarditis not in alliance
with acute rheumatism, I do not know that a single uncom-
plicated case ever fell under my observation. I have, therefore,
been the more curious to look into the experience of others, and
888 what they have found.

Of pericarditis, not in alliance with rheumatism, Corvisart

LECT.XVIl] PERICARDITIS INDEPENDENT OFKllEUMATISM 219

gives five cases ; and it was complicated with inflammation of
other parts in all of tlicni except one ; and in this one it was
caused by a severe blow upon the region of the heart. Two
of his cases ran closely parallel with those which I have related,
as in other respects so especially in this, that the pericarditis
arose at last, and brought a long previous illness to a fatal
tennination.

A young Creole lady came from Martinique to Paris.
When she was confined, and for six months afterwards, she
managed herself ill in the afiair of nursing. Corvisart was
called to visit her when she was actually dying, and could only
learn that, for six days, she had been sufiering obscure and
indefinite symptoms, and had pointed to the heart as the seat
of her pain. Her pulse was irregular, and her jactitation
extreme.

On dissection, pleuro-pneumonia, especially of the right side,
was found ; and pericarditis, which had filled the cavity with
sero-purulent fluid, and spread a thick coat of lymph over the
entire surface of the membrane. Here was no diagnosis of peri-
carditis during life.* — (Obs. ii.)

An old Creole naval officer, the victim of gout and venereal
indulgences, came ii-om Martinique to Paris. Here, after
being fatigued, he was attacked with low fever. In the course
of the fever he became delirious, and suflered an incomplete
paralysis of the left arm. Then his breathing was impeded,
then his pulse was irregular, and he died.

On dissection, serum was found abundantly effused between
the membranes of the brain and into the right lateral ventricle,
the inferior lobe of the right lung hepatised, and the right
pleura covered with lymph and a sero-purulent fluid in its
cavitj^, and the pericardium containing the same kind of fluid,
with a plaster-like substance upon its surface. Here, too, there
was no diagnosis of pericarditis during life. — (Obs. iii.)

Another case was unlike these, and unlike any which I have
given. A strong middle-aged man was seized, in the midst of
health and without any obvious cause, with dysj)na3a, and an
acute pain in the lower and left region of the chest, and on the
same night with a tremendous shivering fit. On the day but
one afterwards he was admitted into the hospital, already sub-
* Corvisart, Essai sur Ics Mai. du Ccjcur.

220 CLINICAL MEDICINE. [lECT. XVII.

clued by his disease, with his pulse small and fluttering and
irregular, his features collapsed, convulsive movements of the
face, hurried resjjiration, and pain in the pra^cordial region.
It did not appear that any treatment had hitherto been era-
ployed, and what was now practised was useless. In two days
more he died.

Here were found, upon dissection, the effects of pleuro-
pneumonia of the left lung, which involved the diaphragm,
and of extensive pericarditis. But there was evidently no dis-
tinct anticipation of pericarditis from the symptoms. — (Obs. i.)

In another case the disease, whatever it was, was success-
fully treated ; but that it was pericarditis, one may be allowed
to doubt. Pleurisy was a part of it, if not the whole. The
atfecticn came on, after great exertion, suddenly, with a violent
rigor, and with extremely severe pain — first in the region of
the heart, and soon extending itself over the entire left side of
the chest with dyspnoea, delirium, and insupportable anxiety.
The patient was a female, and the catamenia occurring on the
third day of the disease seemed to carry away its most alarming-
symptoms, although no remedy whatever had hitherto been
emploj^ed ; the catamenia stopped, and the symptoms returned
with their first intensity. On the 10th day from her original
seizure, she was admitted into the hospital, with symptoms
which would, now, be considered to denote the left cavity of
the pleura full of fluid, and its inflammation relieved, but not
entirely cured, by the effusion. After remaining twenty-three
days under judicious antiphlogistic treatment, she was discharged
convalescent. — (Obs. v.)

The single uncomplicated case remains to be noticed, where
pericarditis was caused by a severe blow upon the region of the
heart. It might have been a fortunate specimen for studying
disease in its simplest character, had it but been seen earlier.
For not only was it an inflammation of the pericardium exclu-
sively, but its cause was of the simplest kind, viz. mechanical.
Its proper symptoms, however, as a disease, were past before
the patient reached the hospital, and what remained were its
irremediable and inevitably fatal effects. But still there is a
very great interest belonging to this case, and that interest is
contained in the uncomplicated character of the disease, and its
simple mechanical cause.

LECT.XVIIJ rERICARDITIS INDEPENDENT OF RHEUMATISAI 22 1

The puticnt, it seems, was dying when ho was admitted.
ITis pulse was " small, frequent, unequal, intermittent, and
irregular;" his eyes were "sunk," his features "much
changed." One remedy was ventured upon — a bleeding; but
it was not repeated, and nothing else was tried, llencotbrth,
to his death, the record of his state is very succinct, and is com-
prised in " countenance more and more hippocratic ; breathing
continually interrupted, and very difficult ; pulse vacillating,
and scarcely perceptible; prostration of strength extreme
notwithstanding the use of cordials ; a spontaneous and almost
sudden dissolution of the right eye, from a suppuration which
took place in it without being preceded or attended by any
inflammatory symptoms ; at length, features entirely changed ;
j)ulse imperceptible; debility extreme, even to fainting; death."
But though dying when he was admitted, and though every
recorded symptom thenceforth gave notice and threatening of
death, he did not actually die until after the lapse of nineteen
days ; and after death the enormous quantity of nearly four pints
of sero-purulent fluid was found distending the bag of the
pericardium, and its whole surface covered with a thick crust
of reticulated albumen. Except that the left lung was pushed
upwards, while it still was spongy and crepitous, there does not
seem to have been the least change, either morbid or mechanical,
found in any other internal organ of the body.

What a vast amount of disease was here accumulated upon
the heart ! How is it possible that the heart could bear it so
long, or bear it at all ? Why, consider all was sound and perfect
throughout the body, from first to last, except the heart. Its
disease reached it from no previous malady of the constitution.
It was received from no other organ by it, and it was imparted to
no other organ from it. It began, proceeded, and ended in
the heart. — (Obs. iv.)

Such are Corvisart's cases, and such the sum of what it has
appeared to me useful to remark upon them.

xindral gives six cases of pericarditis not in alliance with
rheumatism, of which three were complicated and three were not.
His three complicated cases have a remarkable coincidence
with some of those cases which I have given from my own
experience. In one, the pericarditis was complicated with
tubercles and vomica} of the lungs ; in another, with chronic

222 CLINICAL MEDICINE. [lECT. XVII.

asthma and bronchial congestion ; in the third, with petechial
small-jiox. In all three there was reason to believe, that it
came on just prior to dissolution, and in none of them was it
the object of clinical diagnosis during life. Andral, Mai. du
Cceur. — (Obs. V. vi. vii.)

Of his three uncomplicated cases one, which recovered, is
not regarded quite with certainty by Andral himself as a case
of pericarditis. It probably was so. Its symptoms set in with
fever, vertigo, and apparent cerebral congestion, which were
followed by severe jiain in the prajcordial region and epigas-
trium, and very irregular and tumultuous action of the heart.
These yielded to venisection, and several applications of
numerous leeches, and the patient got well. — (Obs. iv.)

Another is a case of exceeding interest. The patient, a
shoemaker, thirty-one years of age, was admitted into the
"Hopital de la Charitc" on the third day after his attack, and
gave this account of himself :— that, three days before, he had
been seized Avith rigor and a general sense of illness, and that
during the following night he had much fever, and the next
day he felt a very sharp pain in the left breast. The next day,
the day of his admission, this pain continued. The following-
was the record now taken of his symptoms : — Countenance pale
and expressive of suffering and inquietude ; a sardonic smile
from time to time, and a sort of convulsive trembling of the
lips. Pain in the prcccordial region habitually of no great
amount, but now and then becoming much more severe, and
then not confined to the seat of the heart, bxit passing, like
strokes of fire (such was the patient's comparison), into the
whole left side of the thorax ; while at the same time the
entire left arm was seized with numbness, which would be
exchanged, during a few seconds, for a very sharp pain.
Whenever the pain was thus exasperated, and darted in these
directions, the breathing was at once greatly impeded, the beats
of the heart became tumultuous, and indescribably irregular,
the pulse imperceptible, and the extremities icy cold.* I)ut
the pain no sooner abated again, than the breathing lost its
agony, and became only moderately embarrassed, the beats of
the heart were again regular and forcible, and heard over the

* This sudden agony has already been noticed as incident to rheumatic
pericarditis. — p. 154.

LECT.XVIl] PEKICAEDITIS INDEPENDENT OF KIIEUMATISM 223

wliolo anterior part of the thorax, and the pulse was raised a
little, but always remained very small relatively to the force
of the heart's impulse. The chest was every where resonant to
percussion, and the respii'atory murmur was everywhere strong-
and clear.

What a strange group of symptoms we have here ! Dis-
tinct paroxysms of angina pectoris following close upon fever
and pains, which had newly arisen and seemed to denote acute
inflammation ! Let us see how it all will end. The disease
was yet only four days old, wlien this was the condition it had
brought the patient to.

'^riie great force of the heart's impulse in the intervals of
the i)aroxysms led to the employment of venisection and
numerous leeches, and during the following night the paroxysms
of pain were loss severe and less frequent. And so they were
during the Ibllowing day, when they returned only three or
fo\ir times; but they were still of the same character and
extent, and still accompanied by the same numbness and pain
of the Avhole arm down to the hand. In the evening, another
venaesection was adopted. The next night was good ; and on
the next day the report was given in these few Avords — " almost
the same state." Nothing could well be more promising than
the patient's condition on the ensuing day, which was the sixth
of his disease. All pain was gone. His aspect had become
more natural. The impulse of the heart was of less force and
less extent. The beat of the arteries, however, was still ex-
tremely small. But now came the change. A few hours after
the physician's visit, without any return of pain, great dyspnoea
arose, which went on increasing until the next morning ; when
the pulsations of the heart, which had all along been so
energetic and forcible, could scarcely be heard within the chest ;
and the beat of the arteries was smaller than ever, and the
entire praccordial region and a considerable space beyond it
Avere dull to percussion. The horizontal posture was impossible,
and as the patient sat erect, he could scarcely utter a few intel-
ligible words in a gasping voice, and express that he felt as if
a chain of iron was being drawn tight round his chest, and wa»
suffocatino: him. lie died in the nio-ht.

On dissection, the bag of the pericardium was found dis-
tended with blood. It contained nearly a quart of a brownish-

224 CLINICAL MEDICINE. [lECT. XVII.

red fluid, liaving the sensible qualities of blood drawn from a
vein. The internal surface of the pericardium was lined with
membranous concretions stained red. No other parts of the
body had undergone any change, save what belonged to sangui-
neous engorgements and congestions, which were evidently
secondary. — (Obs. iii.)

A woman, twenty-six years of age, mother of two children,
and having latel}' suffered a miscarriage, was admitted into La
Charite in such a state of delirium as made it impossible to
gain from her any information respecting her previous condi-
tion. She preserved an obstinate silence, and, being interro-
gated, put on a fixed look, but answered nothing. Her face
was pale, and her lips were kept apart, and agitated from time
to time with a convulsive trembling. Her pulse was frequent
and small, and her skin had little heat. The two next days
there were observed frequent tossings of the head backwards,
and sudden jerking of the trunk upwards, and twitching of the
tendons. She spoke, and seemed to understand ; but her dis-
course was full of incoherence. Her pulse was intermitting,
as well as very frequent. On the following day, the fourth
from her admission, the delirium ceased, and she only com-
plained of great weakness ; but the muscles of the face were
almost continually agitated with convulsive movements, and the
upper extremities presented from time to time a cramp-like
tetanus. On the fifth day the delirium returned ; the features
motionless and changed ; the upper extremities being raised,
fell by their own weight, as if paralytic ; she passed into a
comatose state, and died in the evening.

When the body came to be opened, neither the brain nor the
spinal marrow, nor their investing membranes, nor the intestinal
canal in its entire length, excej)t that here and there it presented
a slight injection, nor the hmgs, except that they w'ere slightly
engorged at their posterior part, nor indeed any other organ,
offered a trace of disease ; but only the heart. Yet not the
substance of the heart, nor any of the vessels coming to it and
going from it, but the pericardium alone. The pericardium
was lined with albuminous concretions, from which soft bands
of adhesion proceeded from one surface to the other, while
there were some oimces of greenish flocculent sermn in its
cavity. — (Obs. viii.)

LECT. XVII.] FliOM DETAILS nilNCIPLES. 225

J^ow I can only hope tliat this lecture of dotuils lias not
drawn too much upon your patience ; for I can hardly expect that
your interest has kept pace with the recital of cases which I
have given from my own observation and that of others. But
these cases must be allowed to contain many important facts,
which, not being able to reduce them under any general head,
I could not have brought forward at all, but as they were
exhibited in particular instances. Be it, however, remembered,
that all our knowledge was originally derived from cases. And
cases must still be noted and jDreserved, and studied, as records
of what we know, until we arrive at more general facts or
principles than we have yet reached. For general facts or
principles, well ascertained, are found both to comprehend
numerous particulars, and to become at the same time their
representatives, and so to dispense in some measure with the
necessity of detailing them.

The subjects of our profession require to be treated sum-
marily or in detail, according to the degree of light that is
brought to bear upon them from a general pathological
principle. If you enter a spacious room with a small taper,
you must carry it about, and pick your way with it into corners
and recesses, and round pillars and projections, and after all
you will hardly know where you are, and will be lucky if you
escape accidents. But if you enter the same Avith a bright
burning lamp, you have only to place it on a pedestal, and then
stand in the midst and look around ; and then you will find all
things, great and small, near and remote, brought out equally
to view, and will at once understand and admire the beauty and
proportions of the whole apartment.

So it is with our clinical inquiries. We must deal much in
detail, we must note cases one by one, while we yet want a
great pathological principle, which can show their natural
relations and reconcile them together. But once establish such
a principle, and it will compass and illustrate perhaps a hundred
particulars at once, and render their minuter examination
needless and superfluous.

15

226 CLINICAL MEDICINE. ] LECT. XVIII.

LECTURE XVIII.

IMMEDIATE RESULTS OF ENDOCAE-DITIS AXD PERICARDITIS.

REPARATION OF THE INJURY DONE TO THE HEART. PERFECT

AND IMPERFECT. — THOUCJH IMPERFECT, IT MAY SAVE LIFE.

CAUSES WHICH HINDER OR POSTPONE REPARATION : 1. THE
AMOUNT OF INJURY TO THE HEART ITSELF ; 2. THE AMOUNT
OF CONCOMITANT INJURY TO OTHER ORGANS; 3. ORIGINAL

WEAKNESS, OR PRAVITY OF CONSTITUTION. ALLUSION TO

CERTAIN AFFECTIONS OF THE BRAIN AND SPINAL MARROW
INCIDENT TO THE PERIOD OF REPARATION.

Our attention has thus far been occupied with acute inflamma-
tion of the heart, as it is found in those structures of the organ
which are its most frequent seat; and we have dwelt especialh'
upon its clinical diagnosis, and its clinical history, and its
medical treatment.

Its clinical diagnosis is, perhaps, as nearly perfect as it is
possible to conceive of any internal disease. The fact of its
existence, even as soon as it begins to exist, and the discrimi-
nation of its exact seat, whether in the endocardium or the
pericardium, are brought to an almost certain calculation.

Its clinical history is less perfect than its clinical diagnosis;
but it will probably be enlarged by future research, teaching us
more of the conditions, both external and internal, which con-
duce to it. What, however, it has already disclosed is most
valuable. It has shown that endocarditis and pericarditis are
no isolated pathological facts, but that they claim a natural
alliance with well-known forms of disease in other parts of the
body, and in the constitution at large.

Its medical treatment can hardly be thought to have reached
all the certainty and success of which it is capable. But, st>
far as it is successful, it claims for endocarditis and pericarditis
(not less than their clinical history claims for them) a common

LECT. XVIII.] RESULTS OF ENDO- AND PERICARDITIS. 227

pathology with inflammation in all other parts, showing that
they botli need and bear the same remedies, and that they
admit from them the same impressions, whether for palliation
•or for cure.

From what, then, has hitherto been seen o£ diseases of the
heart, it will appear how far they stand alone, and how far
they do not. They stand alone in the forms and modes of
their manifestation, but in their essence they have a patho-
logical unity and a common principle of treatment with the
diseases of other parts; they owe their exclusive forms and
modes of manifestation to the structure and functions and sensi-
bilities proper to the heart, of which no other organ in the
body has the like: they owe their unity of essence and their
common principle of treatment to the one vascular system, the
one nervous system, and the one nutrient and assimilative
system, which belong to the heart as they do to all other
organs, and which carry on the work of health and the work of
disease there and every where.

These are truths too well known to be dwelt upon. I only
here set them up as cautionary notices, while we still pursue
our inquiry into diseases of the heart, not to lose the links
connecting them with those of every other organ of the body.

Of acute endocarditis and pericarditis, under the circum-
stances in which alone we have an 3^ familiar experience of their
'occurrence, viz. in connection with rheumatism, the fatal cases
were few; but the cases of perfect recovery, as far as our obser-
vation reached, were few also. Of ninety cases, death took
place in three only. But of the rest it was only in seventeen,
that we could feel any thing like an assurance of perfect
recovery.

What, then, became of the seventy cases which remained?
The patients were kept in the hospital until they had reached,
it was thought, a state of present security ; and then they were
discharged, and lost sight of altogether; believed to be safe
but known not to be sound.

Our acquaintance with the seventy cases in question ceased
at a most interesting point. The most vital organ in the body
had suffered inflammation. The inflammation was goae, but
the organ was still damaged. Life was safe, but recovery was
imperfect. This, I say, was a most interesting point, whether

228 CLINICAL MEDICINE. [lECT. XVIII.

we looked from it backward or forward. In some we had good
reason for gratulatlou, in some for disappointment. Looking-
backwards upon all the fears we had of the severer cases, we
were content that life was merely safe when we expected death :
and looking backward upon all the hopes Ave had of the milder
cases, we were dissatisfied that life was merely safe when we
expected complete recovery. And now in all, safe as the}''
were for the present, looking forward and thinking what was
to become of them, we found them invested with a new interest
prospectively; and at this point of new interest we lost sight
of them. The poor patients remained under our observation
and care for the longest period that the regulations of the
hospital would allow, and then they returned to their customary
occupations, whatever they might be, and followed them as best
they could.

What may be the ultimate fate of these cases will serve for
our speculation hereafter. The fact of their present safety is
momentous enough to have a little further consideration now
bestowed upon it.

This state of present safety was sometimes easily and
quickly reached, and sometimes hardly and slowly; and the
process of reparation conducting to it was full of eventful
circumstances.

But what is reparation? It is neither health nor disease;
but it stands midway between them, and partakes of the nature
of both. Now it is nearer to one, and now to the other; now
ready to fall back into disease, and now to go forward into
health. Truly this reparation demands as much of the physi-
cian's care as either of the other two ; for it has its aids and its
hindrances, which it is our business to study and to interpret;
its aids, that we may apply them and cherish them, and in
every way make the most of them; its hindrances, that we
may intercept them or lessen them or counteract or annul them
altogether.

Unquestionably it does often happen, even when vital
organs are concerned and inflammation has materially injured
their structure, that, as soon as it is fairly arrested, the patient
is safe for the present. There may yet remain a great deal to
be done before he is either entirely well, or as well as he ever
will be; but already there is no anxiety about his life. On the

LECT. XVIII.] REPARATION OF INJURY. 229

other hand, it often happens, when vital organs are concerned,
and a material injury is done, that though the inflammation
have come to an end, life is still in jeopardy. It is not enough
that the disease, as an active, moving, mischief- working process,
have ceased, reparation has to take its place, and to make some
real progress before the patient is safe from day to day.

Inflammation of the heart in its several forms furnishes
examples of both these issues, and happily of one much of tener
than of the other. Simple endocarditis is by far its most fre-
•quent form : and of simple endocarditis the cases in which the
danger, whatever it has been during its progress, entirely
passes away when the inflammation ceases, are the vast majority,
and those in which it remains are the very few. But of simple
pericarditis, and of pericarditis combined with endocarditis, the
•cases in which the danger passes away are the few, and those
in which it remains are the many.

Seldom to endocarditis, oftencr to pericarditis, and very
-often to the complex of both, there succeeds an interval of
days, or of weeks, even of many weeks, during which it is still
doubtful whether the patient will live or die.

Now there is no more obvious and intelligible cause of life
heing left or not left in a state of present safety, or near to it
or far from it, than the mere amount of damage done to the
heart by the by-gone inflammation. After the subsidence of
simple endocarditis, the endocardial murmur will often remain
as loud or louder than ever, showing that the damage done
continues, while at the same time there is no other attendant
condition which denotes the smallest danger. Surely in such
cases there is reason to believe that the damage is small, con-
sisting in those little beads of lymph deposited upon the free
edge of a valve, which dissection discloses as the eftect of acute
inflammation. And, though there be no reparation of this
small damage either now, or for weeks or months to come, life
in the mean time is perfectly safe. No doubt from the valvular
unsoundness produced by endocardial inflammation, though
small in degree, there is a danger, but it is not yet ; and it is
for the sake of preventing this remote danger that its perfect
reparation, small as it is, is especially desirable, and not for the
sake of present safety.

But, after the sub.sidence of simple endocarditis, the murmur

230 CLINICAL MEDICINE. [lECT. XVIII.

wliicli remains will in rarer cases be accompanied by conditions,
tbat bespeak danger, by excess of impulse and by prsecordial
fluttering and by extreme anguisli. And here it may be
believed that a greater damage has taken place. For acute
inflammation of the endocardium can do more than deposit
specks of lymph upon the edges of a valve ; it can spread a
layer of lymph over a great superficial extent, even (as I have
seen) throughout an entire auricle ; it can accumulate masses
of lymph as large as a pea or a cherry-stone, or larger, and
leave them pendulous into the cavity of the ventricle ; or it can
destroy half a valve by ulceration, or carry away a long strip
of the membrane, and lay bare the muscular substance ; or, (as
I have known,) it can penetrate from one auricle to the other,
and lay them both together. Here are some forms of injury
too destructive to admit any such degree of reparation as will
allow life to go on at all ; and here are others not destructive
enough to make such reparation altogether imj)Ossible, but only
capable of it slowly, and likely to keep life in jeopardy until it
is accomplished.

Acute pericarditis being more frequently fatal than endo-
carditis, dissection has made iis more familiar with the nature
of the organic injuries which immediately follow it. Their
forms and degrees are quite enough to accoimt for the many
various events familiar to clinical observation. There is that
organic injury which is too great to be borne, and which must
kill at once, and there is that which is too small to bring life
into any present hazard. In one case there is no surviving it,
the injury is so great, and in another there is no dying of it,
the injury is so small. And as in pericarditis there are many
degrees of organic injury lying between the greatest and the
least disclosed by morbid anatomy, so between present death
and j)resent safety there are degrees and vicissitudes of sufter-
iiig, I:nown to clinical observation, which may come sometimes-
nearer to one, and sometimes nearer to the other.

IS'ow some clear notion of the real detriment done by peri-
carditis, and of the much or the little that remains to be re-
paired is needed to help us in understanding what. its reparation
must be as a living process, and why it is so difficult and so
precarious in some cases, and so easy and so sure in others.
Coagulable lymph adhering to the surface of the ]3ericardium>

LECT. XVIII.] KEPARATION OF INJURY. 231

and fluid cfi'used into its cavity, each of various amount and of
various relative proportions in several instances, constitute the
material results of recent acute inflammation. The coagulable
lymph adhering- to the surface may be deposited in distinct and
broken patches, or it may assume the form of an adventitious
membrane. The adventitious membrane may cover a small
portion only of the pericardium, or it may serve as a complete
lining to it, following its reflections both where it is loose and
over the heart itself and over the large blood-vessels.

This lymph varies in consistence, from the least possible
degree of tenuity, which can preserve a continuous texture, to
the thickness of more than an inch. On one' side, where it is
applied to the pericardium, its surface is imiform ; on the other
it varies. Sometimes this latter is dotted all over with minute
ajiertures or pores at regular distances, which give it a reti-
culated appearance, like delicate net-work. Sometimes it is
intersected with lineal elevations, forming a grosser reticulation,
not unlike the second stomach of the calf. Sometimes it is
studded with minute tubercles ; and sometimes rendered rough
and very unequal by partial accumulations of soft flocculent
matter upon it, like large pieces of sponge, or tow.

From the slight red tinge often observed in this adventitious
membrane, it might be suspected that blood-vessels are continued
into it from the pericardimu. From its capacity of receiving
injection from the coronary arteries, it is certain that they
are so.

The fluid eflused into the cavity of the pericardiiun in con-
sequence of inflammation, varies very much in quantity : some-
times it does not exceed the quantity of fluid ordinarily found
there ; but its appearance will always show it to be the pro-
duct of disease. Nearly four pints are mentioned, upon good
authority, as having been found in a case of inflammation. I
never found more than half as much. This fluid is sometimes
of a clear lemon colour, and transparent; sometimes less trans-
parent, from an intermixture of filamentous flaky or mem-
branous substances ; and sometimes not at all transparent, but,
like unstrained whey, from an intermixture of pus. In different
cases it presents every tinge of red, from an intermixture of
blood in various proportions, and sometimes it is a mere turbid
serum.

232 CLINICAL MEDICINE. [lECT. XVIII.

Here is detriment enougli done to the natural and healthy
structure of the pericardium. Here are substances enough
superadded to its natural and healthy substance. But even to
the eye of the anatomist they bear the characters of transition
and variableness, and not of permanency. They contain the
evidence of something in progress, which death has arrested.
Had life continued, either disease would have increased them,
or reparation have lessened them. They could not have re-
mained as they are. AVhat death has in truth arrested, is either
the growing fabric of disease, or the growing work of reparation ;
for these arc the appearances found, when life is cut short, while
we are still employing active remedies for active symptoms, the
symptoms (we believe) of inflammation. And these too are the
appearances found, when active symptoms have existed, but are
now gone, and active remedies have been used but are now aban-
doned, and inflammation (we believe) has ceased; and yet life
is cut short while wo are helping the faint efibrts of the con-
stitution, and still waiting and hoping for reparation to reach
the point of present safety.

What is thus shown to be true of endocarditis and pericar-
ditis, when each is taken alone, is, without further explanation,
at once seen to be true of them when both are taken together.
It is simply this, that the different amount of organic injury
remaining, after the inflammation has ceased, is one sufficient
reason of reparation being found quick or slow, easy or difficult,
in different cases, to reach the point at which life shall be safe.

These are matters plain and obvious enough, it is true.
Nevertheless they need to be strongly insisted upon, for they
have an important bearing upon practice. In every case of
cardiac inflammation, think of its local effects, and then strive
by all means to cure it, and above all, strive to cure it quickly.
For the longer it lingers, the greater will be the amount of organic
injury which it leaves behind, and the greater the likelihood
that a painful precarious period will succeed before life is safe.

But besides the absolute amount of injury done to the heart
itself, whether small or great, other conditions, just as plain and
palpable, often exist elsewhere, which have a share in deter-
mining how soon or how late, with what ease or what difficulty,
that measure of reparation shall take place, which is to put the
life of the patient in safety again.

JLECT. XVIII.] HINDRANCES TO REPARATION. 233

The coincidence of inflammation of the lungs with inflam-
mation of the heart * has been already pointed out. That in-
flammation may be of any or of every pulmonary structure.
It may be bronchitis pneumonia or pleurisy ; one of them alone,
or two of them, or all of tliem united. And these, when they
so occur, are apt (it will be remembered) to run on to those
terminations which we most deprecate, to large bronchial
eff'usion, to large pulmonary congestion or hepatization, and to
single or double hydrothorax or empyema.

Now, as the life of the patient was doubly jeoparded by the
coincident inflammation of the two vital organs while it was yet
in progress ; so, when it has come to an end, the remaining
organic injury of both makes the work of reparation longer
and more difiicult, and postpones the safety of the patient to a
more distant day.

But, as the peril of inflammation, while it is yet progressive,
is not always in exact proportion to its extent within the part,
so neither, when it is brought to an end, are the chances of
safety and reparation to be measured absolutely by the amount
of the material injury done.

The whole body has to do with the health of its single parts,
and it has to do with their diseases also, in originating and
maintaining, in arresting and repairing them. Look to the
mere matter and bulk of things, and think only of what is
visible tangible and audible in parts, and you will come to
strange conclusions : you will see people die of too little to kill
them, and see people survive what is enough to kill them
twenty times over. But if, in such events, you would know
what it is that mainly kills, and what that mainly saves, you
must look out of the part into the constitution at large : you
must do so especially in diseases of the heart.

It goes hard with weak, scrofulous children, and with men
and women whose habitual health is no better than an habitual
infirmity, Avhen they come to sufier inflammation of any vital
orsran : but it often ffoes still harder with them after the inflam-
mation has ceased, if much be left for reparation. Subjects of
this unhappy constitution will struggle through a combined
attack of inflammation of the heart and lungs, and hold out

* Vide Lecture IX.

234 CLINICAL MEDICINE. [lECT. XVIII.

well until it has come to an end, and will afterwards die during
the halting, ineffectual efforts of reparation, or only after a very
long time, and many vicissitudes, will reach the point of safety
at last. Their constitution has given all it could to the disease
without dying, and it has now not enough, or scarcely enough,
left to give for reparation, or, rather, for that degree of repara-
tion which is needed for present safety.

What that degree is, cannot be accurately told. Yet the
liabitual health of individual patients will furnish a kind of
measure of what it is likely to be in them. The worse their
natural constitution, the less injury can be borne, and the
nearer must the injured organ have returned to the state of its
former integrity before their life is safe.. This, unfortunately,
is as much as to say that the most reparation is needed, where,
in the nature of things, the least can be expected.

As it has been chiefly in weak, scrofulous children that I
have witnessed this struggle for life, or this state of insecurity,
most prolonged after the inflammation has ceased, I shall take
from them the type of certain conditions which I wish to
describe.

Some, when the time has come that they should show the
visible tokens of recovery, have exhibited a perilous prostration
of the nervous system, and such alternate rallying and sinking
as have kept the bystanders in ajjprehension of their death for
weeks and weeks together. But recovery from this condition
is more frequent than death, such a recovery, I mean, as reaches
a state of present safety, but still with an unsound heart.

Some, when we have looked for their visible recovery, have
sunk into anaemia ; ana}mia so extreme and so protracted, that
with them it seemed as if their food would never again be duly
converted into blood. Yet these, too, may, and commonly do,
at length reach a state of present safety ; but still with an
misound heart.

It is most important to remark that, while this prostration
of the nervous system, or this antemia, has lasted, whether for
weeks or for months, reparation has been at a pause. JS^either
the heart, nor the lungs, nor the pleura, if they happen to have
suffered damage, have seemed to make any progress in tliemeau
time towards regaining that degree of soundness of which they
■ are capable.

LECT. XVIII.] HINDRANCES TO EEPARATION. 235-

During the pause of reparation, and in the midst of thia
nervous faihirc, or this impoverislmient of blood, the feet and
ancles are apt to swell, an event which is looked upon as a mere
accident of debility, and is hardly taken into account in calcu-
lating the fate of the patient. But sometimes this small osdema
will rise rapidly into general droj)sy, and serum be found
wherever it can find its way, filling cavities, and distending the
cellular texture throughout the body. Thus, the largest and
most pervasive of all diseases, which is commonly reserved as
the last fatal result, when the heart has reached the most ex-
treme degree of disorganisation that it is capable of, is some-
times an early consequence of its acute disease, arising partly
out of the very damage done by the disease itself, and partlj''
out of the feeble constitution, which it has befallen, being put
to a severer trial than it can bear.

But I have seen recovery even from this condition, the dropsy
entirely dissipated, the patient again safe, and every organ again
free from complaint, except the heart, which has remained per-
manently unsound.

Yet it may not be either the amount of injury suffered by
the heart itself or of concomitant injury suffered by the lungs,
or yet the weakness or pravity of constitution which makes
reparation a halting, lingering process ; it may be none of these
that, after inflammation has ceased, still keeps back the patient
from the point of safety. Nay, the structural damage may
have reached that degree of restitution which should bring
security, and yet there may be something less material and less
defineable, but fearfully real, which continues to hold life in
jeopardy.

Disease is a great physiological teacher. Perhaps it is the
greatest of all. It institutes experiments which we cannot
imitate, and so tells us many things which, but for it, wo should
never know. I never laid bare a living brain, a living spinal
marrow, or a living heart. I never took up a living nerve with
the forceps, or noted the behaviour of these organs severally or
reciprocally under modes of irritation which were of my own
contrivance ; yet, I have read of experiments which I never
performed, and never could bear to see ; and I may have learnt
something from them ; something, how dearly purchased !

But above and beyond all knowledge so obtained, there is a

236 CLINICAL MEDICINE. [lECT. XYIII.

knowledge conveyed by the living phenomena of diseases, and
by them only. Coincident with symptoms referable to the endo-
■^cardiuni or pericardium, in one case there has been maniacal
■delirium, in another epileptic or tetanic convulsion, in another
chorea, in another coma, in another fatuity. The patients have
died, and dissection has found the brain healthy, and the spinal
marrow healthy, and the endocardium and the pericardium
alone inflamed. Now, have all the experiments that were ever
done or perpetrated upon living animals given intimation of
an influence like this, proceeding from the heart to the brain,
and from the heart to the spinal marrow ? Has not disease
here been our teacher ?

All these aifections of the brain and spinal marrow, coming
on in the course of inflammation of the heart, should be carefully
watched and ministered to from the least to the greatest. Wild
-delirium, epileptic, or tetanic convulsion, chorea, coma, fatuity,
. are the greatest and the rarest ; and mutterings, reveries,
transitions from torpor to excitement, subsultus, are the least
and the most frequent. But they are all akin one to another.
The least may mount up to the greatest, and the greatest run
down to the least.

Moreover where any of these have been during the progress
of the disease, and the patient has survived, they are liable to be
■continued or to recur during its reparation. Or they may then
arise for the first time, as if they took advantage of the weak-
ness and exhaustion of the nervous system.

A year or two ago I saw a young lady seventeen or
eighteen years of age, who had suffered acute rheumatism,
and with it inflammation both of the endocardium and pericar-
dium. As active symptoms declined and active remedies were
withdrawn, her extreme weakness became apparent. Her
nervous system was laid prostrate. Her reason began to totter,
and in a few days her mind was entirely gone. And thus, still
without reason but not without consciousness, living but not
rallying, and her vital functions scarcely kept going from hour
to hour, she remained for several weeks. At length mind and
body recovered together by little and little, and she reached the
point of present safety. But neither mind nor body were so
far re-established, while she continued under my observation,
. as to enable me to see to what condition they Avould permanently

LECT. XVIir.] NKRVOUS SYMPTOMS IN HEART DISEASE. 237

revert. The heart beat with some excess of impulse, and with
a loud endocardial murmur ; and I reckoned on permanent
adhesion oi' the pericardium and permanent unsoundness of the
mitral valve. But, moreover, I still feared and questioned what
would be the eventual state of her mind, and still looked to
some possible evil being engrafted upon her extreme weakness,.
8he was taken home by her parents to the north of England,
and her mind was perfectly restored. But after the lapse of a.
twelvemonth she died of pulmonary consumption.

A young man, twenty-eight years of age, after having-,
suffered rheumatic attacks, which had continued subsiding and
returning during eight weeks, came at length under medical
care. He was now in a state of fatuity, and so continued until,
his strength daily diminishing, in three weeks more he died,
" The pericardium was free from disease ; but upon the mitral
valve, near its edge, there was a perfect row of small slender
bead-like warts."* The case is reported by Dr. Watson, and is-
valuable, among other reasons, especially for this, that it authen-
ticates the pathological connection of these awful affections of
the brain Avith endocarditis. Their connection with pericarditis
is the more acknowledged and familiar fact.

The same physician relates another case, which I will
abridge. A young man, twenty-four years of age, suffered an
attack of acute rheumatism, which was of a shifting character,
and confined him to bed six days. Leaving his bed prema-
turely, he suffered a relapse, and afterwards continued slowly
mending until the eleventh day, when he became restless and
delirious. Hitherto the symptoms referable to the heart had
been equivocal, consisting chiefly of pain. At this time, when
Dr. Watson first saw him, he found the heart's disease suffi-
ciently attested by its irregular action, its excessive impulse, and
its loud endocardial murmur. But it was the state of the brain,
which had now become the great object of interest and appre-
hension. A sort of stupor, or obstinate taciturnity through the
day, passed into distinct delirium at night. Such was his con-
dition for six days, when stupor was exchanged for restlessness,
and restlessness for maniacal frenzy with screaming and vocife-
ration. And then tetanic convulsion alternated with coma, and
in three days he died. Upon dissection, at a small space of the
* Med. Gazette, vol. xvi. p. 93.

238 CLINICAL MEDICINE. [lECT. XVIII.

posterior surface of the heart, the pericardium presented an
adhesion of recent lymph, and the mitral valve and the aortic
valve numerous bead-like vegetations.*

Dr. Watson alludes to another case, without describing it.
A young woman, nineteen years of age, went through an attack
of acute rheumatism, accompanied by inflammation of the endo-
cardium and pericardium : " She lived two months from the
commencement of her cardiac disease ; during that period she
was at times wildly delirious, at times stupid, taciturn, and
almost idiotic, and at times quiet and rational, "f

In one of these three cases given by Dr. Watson, there was
no visible trace within the brain of any thing different from
healthy structure. In the other two, there was some fulness of
the blood-vessels of the brain and some slight serous effusion.
Whether these last really partook of the nature of disease, i.e.
of inflammation ; and if so, what share they had in producing
the symptoms, I will not stop to inquire.

My purpose is, to make you aware that, when endocarditis
and pericarditis have ceased to threaten life in their own way
and by their own direct instrumentality and their reparation
has already begun, they may yet induce perils of a new kind,
and death after a new manner, through the troubled functions
of the brain and spinal marrow.

* Med. Gazette, vol. xv. p. 94. t Ibid.

LECT. XTX.] PERMANENT UNSOUNDNESS OF HEART. 239

LECTURE XIX.

PKRMANENT UNSOUNDNESS OF THE HEART FROM THE INJURY
DONE BY ENDOCARDITIS AND PERICARDITIS BEING IMPER-
FECTLY REPAIRED. CONSEQUENCES. SECONDARY INFLAM-
MATIONS.— THEIR CLINICAL HISTORY. THEIR CLINICAL

DIAGNOSIS. ITS EXTREME DIFFICULTY AND UNCERTAINTY.

— SEVERE AND FATAL CASES. COMMENTARY UPON THEM AT

LARGE.

We have been considering that important period of the clinical
history of endocardial and pericardial inflainmation which inter-
venes between the cessation of the disease and the restitution of
the organ, not to a state of complete soundness, but to a state
compatible with present safety.

But of all organs in the body, the heart can least endure any
imperfection of its natural structure ; and yet in the vast
majority of cases where the endocardium or the pericardium has
been inflamed, some imperfection of structure is left behind :
hence the great interest which belongs to them prospectively.

Now seventy such cases occurred to me at St. Bartholomew's
Hospital in the course of five years. Seventy patients, who had
suffered endocarditis or pericarditis or both, were restored to a
state of present safety, but not of perfect soundness, and then
discharged. It will be by the merest chance that any one of
them will ever be seen by me again ; yet, could they all have
been kept within the reach of medical observation for the rest
of their lives, they would without doubt afford some valuable
results. But the conditions of medical practice do not allow
such lengthened observation of any seventy individual patients.
Our own lives must needs last for many generations to furnish
us an experience of other men's diseases in their entire course,
which last the half or the whole of theirs.

But do not let us make the difficulties of clinical observation
under any circumstances greater than they are. Its end, indeed.

240 CLINICAL MEDICINE. [lECT. XIX,

can never be answered by less intercourse with the sick than is
needed to mark each material change that occurs in the progress
of the disease : more than this it does not require. Thus when
the disease is of an acute kind, and runs its course in five or ten
or twenty days, the physician's intercourse with the patient
must be daily, and perhaps more than once a day. For every
day, and, perhaps, more than once a day, changes are apt to
take place, which must be noted as they arise, if they are to be
successfully ministered to. But when the disease is chronic,
and lasts five or ten or twenty years, this intercourse need not
be oftener than at intervals of months, or even once or twice a
year ; for it is only at such intervals that those changes are-
apparent which are likely to call for his interference. And
these surely are easy terms of making the clinical observation
of chronic disease adequate to its purpose. But it is the oppor-
tunity of making it even upon these terms, which is so difiicult
to be obtained. How rarely has it happened to any of us tO'
have numerous individuals the subjects of any given chronie
disease, so constantly within our reach, that we could see them
and inquire into their condition two or three times a year, for
many years together, or for the whole of their lives I * Thus
all I know, and all I can tell, of what is apt to result from the
heart left in an unsound state by an attack of by-gone inflam-
mation, is drawn, not from following up any certain number of
cases from first to last, but from such accidental experience a&
in the course of years has fallen to my share, and been furnished
by, here and there, a case which I have happened to meet with.

There are some truths in medicine which are based upon
numbers and upon statistical calculations, and which thus carry
with them the highest proof of their certainty. And there are-
others which are and only can be picked up piecemeal and by
accident; yet these maybe equally truth s in themselves, though
they are not equally known to be so : they may be called chance-
truths, lying out of the high road of philosophy ; but
Philosophy is not wise, if she does not step aside to gather
them.

You would wish to know the fate of those who are left with
hearts damaged by the effects of inflammation ; and could I

* Vide p. 94, for an explanation of the different ways by which we gain
our knowledge of acute and chronic diseases.

LECT. XIX.] PERMANENT UNSOUNDNESS OF HEART. 241

give you a summary of events drawn from a complete history
of threescore and ten cases, I should be giving- you both the
truth, and withal the hig-hest proof of its certainty. But I can
only g-ivc you sing-le and scattered notices of events drawn from
a partial observation of such cases as have happened to fall in
my way. And thus I may still be giving- you the very truth,
but without the highest proof of its certainty.

Such cases, then, as have fallen in my way have taught me,
that after endocarditis or pericarditis have left the heart in a
state of unsoundness, but life safe for the present, the period to
which life may be still continued is very various. It may be a
few months only, or a few years ; or it may be many years,
even ten, or twenty, or thirty.

Of these facts I am certain ; but I cannot array them
numerically and statistically : and because I cannot, I can deter-
mine no relative proportion between those who survive months
and those who survive years ; or those who survive few years,
and those who survive manj^ : yet the facts are sure. And,
although they come from casual observation, they admit of
being grouped and generalised, and dealt with instructively,
and fair reasons may be given for their being such as they
are.

Such cases have two principal terminations. Either there
may be a renewal of the same disease in the unrepaired struc-
ture, or in some other structure of the heart, or, the unrepaired
structures remaining as they were left, may become the element
of further detriment to the organ, which is different in kind.
Each of these results shall be taken and considered separately,
and in the mean time it will, perhaps, ajDpear why the course
of events, and the duration of life, are so various in those who
owe their unsoundness of heart to a common cause.

Each of these results shall (I say) be considered separately;
for, although they are found mixed together, the things them-
selves are separate in kind. The one, the secondary inflamma-
tion, partakes of the nature of an accident ; the other, the
progressive disorganisation, springs from an inevitable tendency.
The thing- of accident may or may not be added to the thing of
inevitable tendency at any period of its growth. Fresh inflam-
mation may or may not arise in the heart already unsound, and
tending to further disorganisation.

IG

242 CLINICAL MEDICINE. [lECT. XIX-

Let us first consider tlie clinical history and clinical diagnosis
of the incidental secondary inflammation.

"WTioever has had his heart once inflamed (whether it he the
endocardium or pericardium which is the seat of disease) and
left thenceforth permanently imsound, may have it inflamed
again, and he may die of the second inflammation as he might
have died of the first, or he may escape with his life as he-
escaped before. And not once only, but again and again, his
heart may be inflamed afresh, and in some of these attacks he
may die, or he may struggle through them all and reach a state-
of present safety for the twentieth time.

This renewed inflammation may be either of the endocar-
dium or of the pericardium, or of both. It may arise, as it did
at first, out of an attack of acute rheumatism ; or, though it
came at first from acute rheumatism, it may come independently
of it afterwards.

Remember, acute rheumatism is (if we maj^ so speak patho-
logically) the great parent root of inflammations of the heart.
It is also, undoubtedly, one of those diseases for which men are
found to have a constitutional proneness. When it has been
once sufiered early in life, there is a fearful likelihood that it
will be oftentimes sufl^ered again. Moreover, the first attack is
generally the type of every attack which is to follow. They
may not all be equally severe, but they will all take the same
course, and involve the same structures. If the first involve
the heart, so, probably, will they all. Thus, the thought of a
healthy child first seized with acute rheu.matism is full of sor-
rowful forebodings. Its heart is very likely to be inflamed,
and it may die : but, whether it die or not, its heart is very
likely to be damaged for life. Having had acute rheumatism
once, though it may perfectly recover, it is very likely to have
it again ; and, whenever it again has acute rheumatism, it is
very likely again to have inflammation of the heart as its
accompaniment.

But, certain causes, which are not apt to produce inflamma-
tion of the heart de novo, are found capable of renewing it in its
half-repaired condition. A single exposure to cold, a single
act of intemperate indulgence, or some unusual bodily effort,
in a man of unsound heart (unsound from the effects of former
inflammation), will sometimes bring life into jeopardy, and

LECT. XIX.] SECONDARY INFLAMMATIONS. 24iJ

sometimes kill ; and, dying, he will disclose in the endocardium,
or the pericardium, indubitable traces of a new inflammation,
mixed with the effects of the old.

Still, if what I have seen may bo taken to represent what
g'onerally happens (for I have no statistics to appeal to in this
matter), when the unsound heart is re-inflamed, it is almost
always in consequence of a fresh rheumatic attack ; but it is not
exempt from the possibility of being re-inflamed by other causes.

There are some other circumstances belonging to the clinical
history of this secondary inflammation of the heart which
deserve to be mentioned. Like its primary inflammation, it
also is apt to be associated with pulmonary inflammation, with
genuine pneumonia, with bronchitis, with pleurisy. Then, as
to the secondary carditis itself, it may be either of the endocar-
dium or of the pericardium, or of both. Of these structures,
when both have been formerly inflamed, and both left in a state
of imperfect reparation, one alone, or both simultaneously, ma}"
be inflamed again ; or, when one only has been formerly inflamed,
and left in a state of im^^erfect reparation, it may be that the
other, which was then unaftected, is that which is now inflamed.
In this case the inflammation, while it is secondary as belonging
to the heart, is still primary in respect of the particular
structure which it attacks.

Such, as far as I know, are the conditions under which fresh
inflammation is apt to arise in a heart which previous inflamma-
tion has left unsound. Such is its clinical history ; we now
come to its clinical diagnosis.

Inflammation of a heart previously unsound does not submit
itself to so easy and sure a diagnosis as inflammation of a heart
previously healthy.

Diagnosis is greatly helped by contrast. Where yesterday
there was perfect health and to-day there is disease, a transition
has taken place from opposite to opposite. All we see, and all
the patient feels, is full of novelty and surprise; and, that
disease is involved in the change, we know at once, and we
soon And out its nature and its seat by a closer scrutiny. But,
where yesterday there was not perfect health and to-day there
is disease, doubtless here, too, a change has taken place, yet not
so marked a change that either the patient from what he feels,
or the ph^^sician from what he sees, can be sure that m orbid

244 CLINICAL MEDICINE. [lECT. XIX.

actions of a new and fatal tendency have arisen whicli were not
there before. Thus inflammation will often make secret progress
under cover of an habitual infirmity.

Organs that are unsound of structure are often in pain, and
often baffled in function, and, where new disease befalls them,
how otherwise can they betray it but still by pain and still by
irregular function ? The heart that has a valve thickened and
an orifice contracted, or its pericardium adherent, is apt to suffer
pain, and to palpitate and beat out of time. And, when in
this condition inflammation assails it, it cannot do more
than still suii'er pain, and still palpitate, and still beat out
of time.

Well ! but the heart will tJien do all this in excess, and the
excess, you may think, will surely be a sufficient token of the
new disease which has supervened. Not so surely as you may
imagine. There are no certain measures of pain, of palpitation,
and irregular action, annexed to a given amomit of unsoundness
in the heart. These are ever varying between the least and the
greatest degrees, while the heart's unsoundness remains exactly
the same. The natural sensibilities of the organ render it
obnoxious to a multitude of impressions, some from without and
some from within the body, some appreciable and some not,
which are perpetually disturbing its feelings and its functions
in its state of health. And how much more is this likely to be
the case in its state of unsoundness I And if so, then surely of
inflammation ingrafted upon this unsoundness, the mere excess,
to which we allude, must be a most precarious token.

In short, it is a general truth, never formally declared
perhaps, but well worth our notice and of great practical im-
portance, that organs must be previously sound to show clearly
the nature of the injury or malady Avhich they suffer, and that,
in proportion as they arc unsound, they are spoiled for giving
true expression to the ills which afterwards befall them. The
brain, the lungs, the kidneys, the abdominal viscera, being pre-
viously sound and healthy, proclaim themselves inflamed at
once. But the brain, with a clot of blood lodged within it,
tuberculated lungs, granulated kidneys, a scirrhous stomach, an
ulcerated bowel, have their functions and sensibilities in utter
disorder and confusion, and are not in a condition to give
reqiiisite notice of a new inflammation. A broken instrument

LECT. XIX.] SECONDARY INFLAMMATIONS. 215

is ever out of tune : whatever ]coy you touch, you can never
bring- out the right note corresponding with it.

Jiut in the heart, you may say, there arc always the auscul-
tatory signs to look to. In default of all others, these have
been often found enough to settle our diagnosis. Can they do
as much now ? Are they now self-sufficient ? Are they even
auxiliary ? No ; they are neither ; they even fail ns altogether.
In the first inflammation of the sound heart, they M'cre every
thing. In all after inflammations of the unsound heart, the}^
are nothing. This is the fact, and it is readily explained.

In the first inflammation of the pericardium, there is the
exocardial murmur made by the moving of its roughened
surfaces upon each other. But in after inflammation of the
pericardium, exocardial murmur there is none, and none can
there be if its surfaces adhere completely. And if they adhere
partially and there be a murmur, it will not have the proper
attrition in it, and so will want the exocardial character. In
the first inflammation of the endocardium, there is the endo-
cardial murmur, made by the recent lymph deposited upon a
valve ; and the murmur continues ever afterwards, when the
valve so far falls short of perfect reparation as to remain
thickened or puckered. And then in after inflammations,
observe the puzzle. There is the permanent murmur of the old
unsoundness and the recent murmur of the new disease ; but
how much is due to the old, and how much more to the new, is
too delicate an affair for the nicest ear to discriminate.

But all that has been said still waits for its conflrmation by
cases. And the cases which I am about to relate are chiefly
fatal ones. For so much doubt and perplexity confessedly
hang over the clinical diagnosis of these secondary inflamma-
tions of the heart, that no fair illustration can be given of them
without the proofs afforded by dissection after death. Let it
not, however, be therefore inferred that the fatal cases are the
most frequent. My impression, on the contrary, is that the
secondary inflammation, whether of the endocardium or the
pericardium, is rarely fatal. It may add sometimes a little
and sometimes much, and always something to the permanent
unsoundness of the particular structures, yet it seldom produces
present death, but leaves it to arrive at last from the gradually
and slowly increasing disorganisation of the entire heart.

246 CLINICAL MEDICINE. [lECT. XIX.

In presenting llie few cases necessary to illustrate our
present subject, I must be allowed to comment upon them as I
go along. For it is of no use relating cases at all, unless you
may take them in i:)ieces and examine them as men do models
in a workshop.

In the following case an attack of acute rheumatism, two
years before, had been accompanied by inflammation of the
pericardium, which had left the heart permanently unsound.
A fresh attack of acute rheumatism was accompanied by inflam-
mation of the endocardium, which j^roved fatal.

Amelia West, aged 22, was carried into the hospital, Sep-
tember 24th, 1836. Her countenance was pale, her skin hot
and perspiring, her tongue furred and bordered with red at the
edges, and streaked with red dovrn the centre. Her pulse was
120, and very full and hard withal. Many of her larger joints
were greatly swelled and very painful, and upon the skin,
covering some of them, was a blush of red. Her res]3iration
was short and difiicult, anU her heart beat with an excessive
impulse. Her whole chest (she complained) was bound so tight
that it could not expand, yet auscultation found nothing amiss
in the lungs ; and in the heart it only found what was already
evident to the touch, an excessive impulse. It detected no
unnatural sound.

Such were her present symptoms. Her previous history,
bearing upon her present condition v.-as this, — she had siifi'ered
1wo severe attacks of acute rheuraatii^m bclbre, and this was the
third. The last, two years ago, was accompanied by an aflcc-
tion of the chcd, for which she was bled. Her present attack
began -udth wandering pains, which followed an exposure to
cold, a month ago. These, together with sickness and headache,
continued, and showed neither increase nor abatement until five
days ago, when fever was lighted up, and the joints began to
swell, and the heart to palpitate, and the respiration to fail, and
all had been becoming wor&e and woree irom that time forth
until now.

Here was perilous disease in progress : but where was it,
and what was it ''t Our auscultation excluded the lungs : it
must then be in the heart. The inordinate irajDulse and all the
attendant anguish, arising and increasing as the acute rheu-
matic symptoms arose and increased, seemed to determine that

JLECT. XIX. J .SECONDARY INFJ-AJUfATIONS. 247

liere must, be its scat. ]jut was it inflaramatioii, and in what
part of the lieart Avas its scat ':' Tlio mere excess of impulse
and the severe anguish, did not settle the questions. Symptoms
may be very striking- and prominent in themselves, and yet be
very indefinite in what they denote. And such were these.
But further assuming (as it was practically right to assume,
and we did assume) that the disease was inflammation, either
of the endocardium or the pericardium, was it ingrafted upon
.an unsound heart, or had it come de novo in a sound one Y And
this we could onl}' determine by learning in what state her last
rheumatism had left her, and her present rheumatism had found
her. But the poor patient was too simple and too ill to give
-any intelligible account of the matter ; and we knew nothing
of her until wc found her in her present perilous condition.
Nevertheless, from the fact that in a former attack of rheuma-
tism, the chest was so affected as to need bleeding for its relief, we
ventured to consider the present inflammation (if inflammatio]i
it was) ingrafted upon an unsound heart.

But to proceed with the case. Here were symptoms not to
be trifled with. The fever ran very high. The proper rheumatic
symptoms and all that concerned the joints were very severe,
and very severe too was all that concerned the chest, and, if it
were inflammation, very perilous and very rapidly progressive.
The dyspnoea and prsocordial anguish called for innnediate
relief by some remedy capable of a present imjDression. Ac-
cordingly for this a full cupping was practised. Also the
renewed inflammation was to be abated, and ultimately
abolished. Accordingly mercury was directed, with a view of
bringing the constitution as soon as possible under its influence,
and ten grains of calomel immediately, and ten grains of calo-
mel on the following morning, were given, united with opium.

The dyspnffia and tightness of the chest were at once greatly
•diminished, and the respiration suffered no urgent distress for
the five following days. But no restraint was yet put upon the
violent impulse of the heart. Diarrho3a arose on the third day,
-and interfered Avith the further use of calomel, and so Dover's
powder was employed to meet the urgency of this particular
symptom, as well as to quiet the nervous system.

On the fourth day the gums were decidedly sore, and
swollen, and the tougne was loaded with a yello^^' fur. The

248 CLINICAL MEDICINE. [lECT. XIX

proper rheumatic symptoms were noarl}^ gone, and the symp-
toms belonging to the chest, were restricted to the heart, which
beat with more violence than ever, but still without any
unnatural soimd.

On the fifth morning, after a night of much sleep, she was
said to wake much more comfortable, and so to continue until
noonday, when suddenly the breathing became very short and
painful, and the nostrils were dilated at each inspiration, and
the countenance betokened great distress. The heart continued
to beat with the same violence, but with less frequency, and
now for the first time with a slight systolic endocardial mur-
mur. The gums were very sore. A mustard cataplasm was
applied to the chest, and the Dover's powder was continued.
The cataplasm gave great relief.

On the sixth morning, it was found that the relief of the
chest procured by the cataplasm, had continued through the
night, until nine in the morning ; and then she became faint,
and all the distress of yesterday returned, and Avith it a cold
perspiration, and a sad struggle to dislodge some scanty jjhlegm
which vexed the trachea. The heart beat both with less force,
and less frequency, and no endocardial murmur was percej^tible.
The mustard cataplasm was re-applied, but no relief followed.

On the seventh morning, after a night of agonising distress,
she w^as bathed with cold perspiration ; the trunk of the body
was bent upon the knees, and thus she was contending for
breath, and striving to clear the throat by an effort of coughing,
but in vain. The heart was beating feebly and tumultuously,
but Avithout unnatural sound. Yet in this condition she
struggled through another night, and at nine o'clock the next
morning, after lying an hour upon her back, she expired.

It was matter of interesting speculation what would be
fomid on examination after death. As far as auscultation could
be trusted for negative results, it showed that the lungs had no
share in the disease. Symptoms referable to the heart, viz.
pain and inordinate impulse, v.'hich arose with the new rheu-
matic attack, and afterAvards continued, pointed to this as the
organ affected. But these symptoms were not enough to denote
either the nature or the seat of the disease. A systolic endo-
cardial murmur Avhich came one day, and was gone the next,
— viz. the day before the patient began suddenly to sink, — was

LECT. XIX.] SECONDARY INFLAMMATIONS. 249^

the only symptom to suggest that the seat of the new disease
was tlie endocardium.

l^oth kings had contracted extensive and very intimate
adhesions to the ribs anteriorly. The left pleural cavity, where
it was free, contained about three ounces of sennn. The lungs
and bronchial tubes were healthy. The pericardium was uni-
versally and closely adherent to the heart. The intervening
matter was thick, and at some parts as condensed, and as hard
as cartilage. Both auricles were greatly dilated and choked
with coagula. The right ventricle was simply dilated in a
moderate degree ; the left ventricle both greatly dilated and
greatly hypertrophied ; and in its large carnea) columna; were
some peculiar deposits giving them the appearance of grained
oak. The lining membrane of both auricles was opaque and
thickened. Both the tricuspid and the mitral valves on their
auricular aspects, and near to their edges, had numerous beads
of lymph growing from the surface, but leaving it entire, when
they were picked off by the forceps. In the mitral valve they
formed almost an entire circle : on the tricuspid they were
fewer. Among them there were some that had become much
larger than the rest, even as large as a pea, and were loosely
pendulous into the ventricle. The auriculo- ventricular orifice
had not on either side of the heart undergone any obvious
contraction. Both the pulmonary and aortic valves were free
from disease.

The liver was enlarged, and congested with bile and blood
(W. XX. 121.)

The next case, as it ran on speedily to its fatal termination,
gave a short, and striking, and rapid proof, how the previous
unsoundness of the organ can mar the diagnosis of its subsequent
diseases.

An attack of acute rheumatism, a year and half before, had
been accompanied by inflammation of the pericardium, which
had left the heart permanently unsound ; and a fresh attack oi
rheumatism produced fresh inflammation of the j^ericardiuni..
which killed. The symptoms plainly belonged to the heart,
and plainly showed that it was most perilously affected. But
they were not definite enough, either to characterise the nature
of its disease, or to denote the texture of the organ which it
occupied.

'250 CLINICAL -MEDICINE. [lECT. XIX.

William Bean, aged 12, Avas admitted into the hospital,
Decciubcr 16th, 1833, and died on the evening of the 19th.
His symptoms on admission were these : — skin hot and dry,
tongue moist and white, pulse 140 and jerking, swelling and
slight redness and pain of the right wrist and hand, but of no
other part of the body : breathing hurried and short, with a
slight cough : pain in the precordial region, increased by ]3i"es-
sure between the ribs, and by deep inspiration ; excessive
impulse of the heart ; inability to lie on the left side. Aus-
cultation found the lungs admitting air freel}' in every part,
and at a circumscribed spot beneath the cartilages of the third
a,nd fourth ribs on the left side, the systole of the heart was
heard, accompanied by an unnatural sound of an indefinite kind.
The sound was lost when the stethoscope was removed from this
spot in the least degree.

The history of the present attack could not be made out
with all the exactness which Avas desirable. The boy's father,
and mother, and himself, were all in a difierent story as to when
he Avas taken ill, and whether his chest or his limbs were
affected first. The poor often take small account of what they
or their children suifer short of their being absolutely incapa-
-citated ; and this very circumstance is apt to operate as a bar to
the information Ave seek in many an interesting case. But we
who knoAV the poor are not surprised at it. They do and must
endure daily a measure of (AA^hat Ave should think) phj^sical evil ;
but habit naturally blunts their jJcrception of it to themselves,
and their sympathy for it in others. ^Vnd well it is that it is so.

Thus much, hoAvever, as to our present case, was pretty
certain, that the rheumatism had existed a week at least, and
the symptoms referable to the heart several da^^s ; that the
rheumatism had occupied the knees and ancles of both lower
•extremities as Avell as the hand, and noAV might be considered
on the decline ; and that the symptoms referable to the heart
(Avhich were in truth habitual symptoms of long standing now
greatly aggravated), had been becoming daily Averse and worse.
It appeared, too, that the attack commenced Av^ith a rigor, fol-
lowed by heat and ]Derspiration.

The history of the j)atient's previous state, so far as it bore
upon his present condition, Avas simjjly this. The boy had suf-
fered acute rheumatism a year and a half ago, and from that

LECT. XIX.] .SECOX])AK'Y INFLAMMA'JIOX.S. 251

time lie had never been free iiom palpitation and uneasiness in
the region of the heart, -which he had nut experienced before.

The progress of his symptoms during the brief period whicli
interwncd between his admission and his death, and their trt^at-
ment, it Avill be enough to state succinctly.

Six leeches were applied to the region of the heart, and three
grains of calomel, and a (piarter of a grain of opium, ordered to
be given every six hours.

He was visited at 8 o'clock r.^r. on the same day, and found
dozing. He had been delirious in the course of the afternoon,
but had derived some relief from the leeches, and was now quite
collected.

The next clay, the bowels suffering irritation, the dose of
calomel was reduced from three grains to one, and a drachm of
strong mercurial ointment ordered to be rubbed in night and
morning : after forty-eiglit hours from the time of his admis-
sion a great change had taken place ; the pain and swelling of
the hand had ceased entirely ; the fever was almost gone.
There had been two nights of sleej) and two days of quietude :
even the pain referable to the proecordial region was uncom-
plained of, until it was provoked by pressure, by deep inspiration,
or by lying on the right side. Then the pain was there still.

It may be remarked, that the murmur which on our first
examination was heaid at the cartilages of the third and
fourth ribs, was never afterwards heard either there or any
where else.

Thus it coidd not be denied that the active symptoms of the
disease were abated, and the disease itself was probably brought
to a pause : but there was no sign of rallying withal. The air
passed uninterruptedly through both lungs, still the respirations
were 64 in a minute. The heart was almost without pain :
still it beat tumnltuously, and 150 strokes in a minute. It is a
bad omen when disease declines, and jxt is followed by no token
of returning health ; there is then a fearful expectation of what
may come next. Every function of heart, and brain, and blood-
"sessel, and nerve, was ebbing and running down, but death not
yet in sight, though surely nigh at hand.

On the morrow, the 19th, the third day from his admission,
at 11 A.M., he was found with features collapsed, and lips blue,
imd forehead covered with perspiration, and coughing up a

252 CLINICAL MEDICINE. [leCT. XIX.

scanty mucus, tinged with blood. Respiration 60, and unequal ;.
•pulse 164, and small as a thread ; yet the heart and the carotids
bounding vehemently ; the praecordial region quite free from
pain. We tried to make an auscultation of the heart, and
esjiecially of the lungs, but he could not bear it, and we desisted.
At 2 P.M. countenance was more dusky, and lips more blue, and
respiration more distressed. At 6 p.m. hands and feet cold,
respirations 72, pulse countless ; yet the impulse of the heart
was still great : he was still rational, and free from pain. At
8 P.M. he shrieked out from sudden severe pain, as from spasm,
and in five minutes he died.

On examination after death, the cavity of each pleura was
found to contain four ounces of serum, while the membrane
itself appeared healthy. Both lungs were gorged with blood,
and their lower lobes were becoming hcpatised, and loose of
texture, and yielding to the pressure of the fingers. The heart
occupied an unusually large space in front of the chest. There
was no trace of disease on the pericardium exteriorly ; but being
laid open, it disclosed the distinct results of two inflammations
occurring at distant periods ; viz. certain spaces of such close
and intimate adhesion, that its separation was impossible with-
out either tearing the heart or tearing the membrane, and
certain spaces intervening between these of a loose adhesion, by
means of soft flocculent lymph, largely accimiulated upon its
opposite surfaces, and reaching from one to the other; this
lymph was mixed with serum and blood, from which it had
taken a stain of red. The muscular substance of the heart
bore not any mark of disease, neither did the internal lining, or
the valves.— (M. 19, 130.)

Cases need not be further multiplied (the two which have
been related are quite enough) to show the uncertain diagnosis
and possible fatality of inflammation, renewed by a fresh attack
of rheumatism in the endocardium or the pericardium of a
heart which has been left unsound after a former attack.

But the inflammation does not require an attack of rheu-
matism to renew it ; it will be enough just to give the outline
of a case in proof of this ; a case where endocarditis and peri-
carditis arose, during the progress of acute pleuro-pneumonia,
in a heart which had its pericardium already adherent. Here
the mixture of equivocal circumstances, and the complexity of

■LECT. XIX.] SECONDARY INFLAMMATIONS. 253

the disease threw u veil over one half of it at least, and the
patient was believed to have suffered, and to have died of
pleuro-pneumonia, and pleuro-pneumonia only, nntil dissection
•disclosed the traces of recent inflannnation both without and
within the heart.

Elizabeth Broom, aged 18, was admitted into the hospital
May 30, 1(S36. Fever and frequent pulse, and dyspnoea, and
-cough, and glutinous rust-coloured sputa, at once gave intima-
tion of pneumonia, and auscultation presently confirmed the
same; for a bronchial respiration and a bronchial voice pro-
ceeded from the greater part of both lungs behind, with here
and there some small crepitation, while all below each scapula
was dull to percussion : moreover, auscultation found, coincident
with the systole of the heart, and pervading the proecordlal
region, and conveyed along the aorta and carotids a distinct
endocardial murmur.

A fortnight ago, after exposure to cold, she had been seized
with a severe rigor, followed by heat and dyspnoea, and pain in
the side ; whereupon she had applied to a dispensary, and was
largely bled, and leeched, and blistered : thus some immediate
relief was obtained. But the disease, which Avas onl}^ checked,
afterwards proceeded ; and now, after the lapse of a fortnight,
it was beyond the reach of a remedy. The poor girl was evi-
dently sinking, and had only come into the hospital to die, — to
die of the double pneumonia, as was thought, and nothing else ;
and surely it was quite enough to kill her.

But what meant the endocardial murmur found ever}' where
in the prajcordial region, and conveyed through the arteries ?
It was too prominent a symptom to escape our notice, and it
became our aim to make out what it really meant. Now these
facts were pretty clearly ascertained, — that two years ago the
patient had had acute rheumatism, and that ever afterwards she
had suffered palpitation and frequent uneasiness in the seat of
the heart. Here the rheumatism two years ago, the abiding
palpitation from that time forth, and the present endocardial
murmur, were facts which fitted into one another as compactly
as one could wish, and seemed to furnish a complete proof of
permanent valvular Injury left behind by by-gone Inflammation
oi the endocardium.

It is true that the heart was now beating with some excess

254 CLINICAL MEDICIXK. [lECI'. XIX.

of impulse ; but so it liad been (wo learnt) for the last two years.
It is also true that pain was referred to the left side, somewhere
about the region of the heart, and that to breathe deeply in-
creased it, and to lie on the left side increased it, and also
brought on a sense of suifocation : but then the certain pneu-
monia and the almost certain pleurisy, wore enough to account
for all this.

Accordingly, we bent all our care to relieve the distress of
one dying of pleuro-pneumony, thinking the heart not other-
wise affected than by its old A'alvular injury. In four days the
patient was dead. On examination, we found just Avhat we
expected in the lungs and pleura, but found nothing that wo
did, and every thing that we did not, expect in the heart.

On the left side the j^leura exhibited everywhere the effects
of acute inflammation. One-half of it was adherent, having, by
lymph from its opposite surftices, brought the entire lower lobe
of the lung and the external pericardium in close union with
the walls of the chest. The other half had fluid effused between
its folds, which compassed and compressed the upper lobe. Of
the lung itself on this side, one half, the lower, was infiltrated
Avilli pus, and contained a small circumscribed abscess ; the
other lialf, the upper, seemed b}^ being compressed to have
escaped being inflamed. On the right there were no marks of
pleurisy, no adhesion, no lymph, no fluid. The lower lobes of
the lung presented a state of earlier inflammation, and the
upper lobe a state of emphysema.

But what of the heart ? In attempting to lay open the
pericardium, we found the heart surrounded with bags of pus,
whicli we could not help cutting into one after another. They
Avere partitioned by close and firm intervening adhesions. The
pus and fluid contents of these several bags could not have
amounted altogether to less than half a pint. Within the
heart, the tricuspid, the mitral, and the aortic valves presented
deposits of lymph on their free edges, which admitted of being
T'ubbcd ofl", leaving a rough surface in their place. The oriflces
of the heart were not at all contracted, and the cavities were of
their due capacity, except that the right auricle seemed some-
what dilated. The liver was congested with blood and bile.
(W. 21, 21.)

Here, then, wore displayed within the heart the traces of

LECT. XIX.] SECONDARY INFLAMMATIONS. 25->

two influmnmlious winch occuiTod at an interval of years. The
firm close partial adhesions of the pericardium constituted the
abiding unsoundness produced and loft by the rheumatic in-
flammation two years before, and the deposits of pus which
intervened between them, and the deposits of lymph upon the
several valves, were produced and left b}^ acute inflammation
of the pericardium and endocardium, coincident with the recent
attack of pleuro-pneumon}'.

-256 CLINICAL MEDICINE. [lECT. XX.

LECTURE XX.

-SECONDARY INFLAMMATIONS CONTINUED. CERTAINTY OF OUR

KNOWLEDGE OF SEVERER AND FATAL CASES. — REASONABLE
CONJECTURE OF MANY LESS SEVERE AND MORE MANAGEABLE.
— INFERENCE FROM SUCCESSFUL TREATMENT. DOES IN-
FLAMMATION, AS OFTEN AS IT IS RENEWED, ADD SOME-
THING TO THE PERMANENT INJURY OF THE HEART ?

REASONS FROM ANALOGY AVHY IT SOMETIMES DOES NOT.

REASONS FROM OBSERVATION WHY IT OFTEN DOES. CASE

OF INFLAMMATION MANY TIMES RENEWED IN THE COURSE

OF YEARS AND ULTIMATELY FATAL. COMMENTARY UPON IT

AT LARGE.

The cases whicli have been related may be Idoked u^^on as
giving the stamp or type of secondary inflammation of the
heart. By secondary, you will recollect, is here meant inflam-
mation occurring afresh in the endocardium, or in the peri-
cardium, or in both, of a heart left unsound after prior inflam-
mation, which had aflected one or other or both of the same
structures.

Take, then, this stamp or typo of the disease and examine it
carefully, and you will And that in part it leaves a clear and
legible impression, and in part a faint outline only. The
secondary inflammation of the heart has its clinical history well
made out, not so its clinical diagnosis. The conditions con-
•ducing to it and giving expectation that it will occur, are plain
enough. The signs denoting its actual presence are equivocal
and uncertain.

For the sake of illustrating this secondary inflammation of
the heart, we have hitherto been dealing with its severest and
its fatal instances only. For we were in search of its sure
diagnostic signs ; and its severest instances were most likely
to display them, if any such there were. But, finding no sure
•di ignostic signs even in these, we wanted the proof which fatal

LKCT. XX.] MX'(.)M>Ai;'i 1 MLA.M.MA IK »NS. 257

iiistiinccs wo\ild iilono afford iis, thut the disease, so obscurely
declaring itself during life, liad a real existence. This doubt
could only be set at rest by dissection after death.

The reality of the disease, and its fatal tendency, and its
obscure diagnosis, being all admitted, it became the more
necessary to acquaint ourselves with its coincidents and accom-
paniments, if perhaps by marking them, and being through
them on the watch for it, and knowing when to expect it, we
might catch a glimpse of it in its hiding place, and so treat it,
and arrest it, and cure it.

These coincidents or accompaniments are an attack of acute
rheumatism, or an attack of pneumonia or pleurisy, or an
attack of fever from any cause whatever. And when any one
of these befals a man whose heart has been left unsound by a
prior inflammation, then inflammation is apt to be renewed in
it afresh. And when, imdcr such circumstances and in such a
subject, the heart, which habitually palpitates and is habitually
imeasy, suffers a great increase of palpitation and of pain, then
its inflammation should be assumed as a fact.

It is among the general truths of pathology that parts left
unsound by past disease have a greater readiness to catch
disease afresh, from caviscs c:dculated to conve}^ it, than parts
which never were injured before. As a taper just blown out,
will snatch the flame from the torch that scarcely touches it,
and so rekindle itself at once. Thvis independent of our special
experience, the known pathological principle would teach us
upon any extraordinary vascular excitement, whether inflam-
matory or febrile, to fear for the heart once inflamed and still
unsound, and to watch any new symptoms belonging to it, and
always to make much of them, and even to interpret them to
mean inflammation, though, under ordinary circumstances,
they might safely be not so regarded.

After all, then, you will observe, that, for the actual pre-
sence of this secondary inflammation in any case, and for our
guidance in treating it, we have only the warrant of conjecture.
It is most true.

But there is such a thing as sober conjecture, as well as
sober certainty. And diseases are treated, and cures are
achieved, and lives are saved, as often under the guidance of
one as the other. Such conjecture, however, is altogether

17

258 CLINICAL MEDICINE. [lECT. XX.

different from the arrogant g-uess-work, wliicli lias no basis of
action, and which succeeds once and fails twenty times, and
knows as little why it succeeds as why it fails.

The conjecture which should guide the physician, is rigor-
ous, and calculating, and honest. I't acts strictly by rule and
kaves nothing to chance. It does not absolutely see the thing
it is in quest of, for then it would no longer be conjecture^
But, because it does not see it, it ponders all its accidents and
appurtenances, and, noting well whither they point, it takes
aim in the same direction, and so oftener hits the mark than
misses it. And succeeding thus, it knows why it succeeds, and
it can succeed again and again ui3on the same terms.

Next to knowing the truth itself, is to know the direction
in which it lies. And this is the peculiar praise of a sound
conjecture.

Now, remember, the cases of secondary inflammation of the-
heart hitherto considered have been all fatal cases, all severe,,
all great cases, as you might call them. But there is often a
relationship in medicine between the great things and the
small. And we have learnt a good practical lesson when we-
have found out what the relationship is. It is often such as to
require that the greater should be understood first, and pre-
paratorily. For the nature of both being the same cannot be
well apprehended in its miniature forms, unless it be first
studied in its larger and more striking developments. Nay,.
more, the smaller things being understood, require still to be
handled and dealt with in continual reference to the knowledge
we have of the greater.

No physician trifles with inflammations of the larynx or
trachea. Some of them arc of small account, just tickling the
glottis, and untuning the voice ; and some of them bring great
oppression, from the infinite quantity of mucus perpetually
expectorated and perpetually renewed, yet for the most part
they are manageable enough : and some of them harass and
torment with a scanty tenacious phlegm, which stings intoler-
ably the parts it rests ujDon, and so there is no end of coughing
night and day, yet they, too, for the most part yield to the
power of medicine at last, and are cured.

But there is an inflammation of the lar^mx and trachea,,
which, what with the obstruction and the spasm together that

LECT. XX. J SIX'ONDAKV INFLAMMATIONS. 2-59

are iaduccd by it, shuts out air from the lungs, and sti-ang'lcs a
man to death.

Now this last inflanimution must be known in all its bear-
ings, or our knowledge of all the rest will bo imi)orfect ; for,
being of the same, or at least of a kindred nature, with it, they
all eontain within them the possibility of growing uj3 to the
same magnitude, and placing life in the same jeopardy. There-
fore, in dealing with the least of them, with the mere tickling-
vexing cough, we are to take it for what it is, and treat it for
what it is, but not to forget what it may be. And so of all the
rest.

Now, if living phenomena alone, carefully noted and com-
pared, can be trusted without the aid of morbid anatomy for
fixing by a fair conjecture the reality of a disease, then second-
ary inflammation of the heart has many less severe, many less
intractable forms. Cases are by no means of unfrequent
occurrence, running parallel with those which have been related,
both in what constitutes their clinical history and their clinical
diagnosis, while they are more amenable to medical treatment.
Their preceding and accompanying conditions are still the
same, and equally clear and definite, namely, a rheumatism, a
pulmonary inflammation, or a fever ; and their signs im-
mediately referable to the heart are still the same, and equally
equivocal and ambiguous, namely, augmented imj)ulse and
augmented pain.

These are the common conditions which seem to declare the
individual cases tied together into one species. But what is it
that declares their differences of degree, the more or the less
severe case, the great or the small, the case which is far beyond,
or is fairly within, the reach of medicine ? Nothing, as far as
I know, but the actual trial of medicine itself will manifest all
this. I believe, that whenever the heart is re-inflamed by a
fresh attack of rheumatism, there is almost always a tremendous
accession of palpitation and pain. Oftentimes, however, when
the palpitation and the pain have been the greatest, they have
been most easily subdued. So these are no sure measure of the
severit}^ of the disease, and no sure warning of its fatal result.

I could relate numerous cases of one and the same species
(as I believe) with those which have been already given, yet
in perfect contrast with them as to this single resj)ect, namely.

260 CLINICAL MEDICINE. [lECT. XX.

their readiness to admit the remedial impression of medicine.
Contrasted with the few cases (for they are the few) where, on
a fresh attack of rheumatism, vehement palpitation and proe-
cordial anguish arise, and remedies have no effect in abating
them, and complications of pleurisy or of pneumonia follow,
and the whole man is rapidly subdued, and the end is death :
contrasted with these are the many (for happily they are the
many), where, under the like conditions, palpitation and prae-
cordial anguish just as great arise, but they are readily controlled
and abated by remedies, and no complications of pleurisy or
pneumonia follow ; and the constitution does not profoundly
suffer, and the end is recovery. By recovery I here mean, that
the attack ceases, and leaves the patient in no worse a condition,
as far as symptoms referable to the heart are concerned, than
that in which it found him.

To escape with life from a renewed attack of endocarditis or
pericarditis, and not only to escape with life, but without aggra-
vation of the symptoms which permanently belong to the heart,
are possible and frequent events ; but they can only be ensured
by discreet medical management. In such cases it is important
neither to do too little nor too much. It is true there is a
tremendous augmentation of distress immediately upon the
accession of this secondary inflammation, but the inflammation
is easily made to lose its hold (if I may so say), and the distress
is soon abated.

As to the kind of medical treatment, I would remark gene-
rally, first, with respect to bleeding , that if you now direct this
mode of depletion with the view of entireli/ stilling the violent
action of the heart and arteries, you propose a false and im-
possible indication of practice ; false, because this violent action
is in part permanent, and has not to do with the present condi-
tions of disease ; impossible, because no quantity of bleeding
short of that which would kill the patient would be adequate to
the purpose ; and^ secondly, with respect to mercury, that all
which can now be done is commonly within the reach of other
remedies, and therefore that commonly it is unnecessar3\

Leeches applied to the region of the heart will, by the im-
mediate effect which they produce, test the sort of inflammation
you have to deal with, and show whether any and what other
remedv will be needed in counteraction of it. If they at once

LECT. XX.] TIJKA'l'.MKM' ol'Sl-.COXDAlfV I NJ'I.A.M.M A'llDNS, 201

afford marked relief, tlioy thus denote both that the inflamma-
tion is easily controllable, and that the}', without the aid ot
any other remedy properly antiphlogistic, Avill be able to control
it. And so it will turn out in the majority of cases. lUit ii"
they afford no marked relief at once, or, still more, after their
rejieated application, then they plainly proclaim the inflamma-
tion beyond their power to cope with, and they call for the help
of mercury (as at first) to withhold it from a fatal issue : but this
does not often happen.

In the treatment of these secondary inflammations, it must
always be borne in mind that they are secondary. We must
restrict our practice to the purpose of removing so much of the
disease as is superadded by the present attack, and abstain from
pushing cither bleeding or mercury to such an extent as we
should if we proposed to play a successful after-game for the
complete cure of the disease of the heart, which is impossible.

But these secondary attacks of inflammation which people
suffer and recover from, and suffer and recover from again and
again, do they always add something to the permanent unsound-
ness of the heart P I cannot tell ; but probably not always.

Wliat is that which has really the nature of inflammation,
yet of inflammation in its least degree ? And what is the least
material injur}' which inflammation is capable of doing-' The
following, perhaps, may be regarded as a specimen of both. I
have often had occasion to examine the eye of an indi^'idual who
suffered purulent ophthalmia many years ago. Part of the cornea
is converted into a dense opaque substance^ the cicatrix of its for-
mer injury, and part remains transparent. Often, from inclement
weather, or from any cause operating injuriously on the general
health, a painful sense of fulness is felt in the eye, and presently
its small sphere of vision becomes cloudy ; and, if it be now
examined, these two changes are found to take place, one after
the other, within it. First, the cicatrix is seen to be fidl of
minute blood-vessels, while the rest of the cornea exhibits no
extraordinary vascularity, unless, perhaps, there be a single
vessel running across it, and carrying its blood straight into
the cicatrix. >Secondly, a little nebulous curtain is seen all along
the margin of the cicatrix, as if it were falling down from it
upon the transparent portion of the cornea. In a couple of
days, without an}' special remedy, merely by care to avoid

262 CLINICAL MEDICINE. [lECT. XX.

external cold and by abstinence from stimulating diet, the eye
loses its painful sensations, and its small sphere of vision becomes
again clear ; and, being then examined, both the vascularity of
the cicatrix and the nebulous curtain that hung from its border
have disappeared.

Exactly the same malady will occur many times in the
course of the year, and exactly the same processes of disease and
reparation will display themselves many times in the eye and
leave it just as it was before. Here, surely, are both inflamma-
tion and material injury, the effect of inflammation. Yet how
small are they ; small both in degree and in extent ! How
easily produced, and how easily and entirely cured! But,
observe, the inflammation is of a new structure, entering into
the comj)osition of the unsound part, and it comes and it goes,
iind docs its little temporary injury, and, after all, adds nothing
to the permanent unsoundness.

JN'ow, may we take this slight secondary inflammation of an
unsound structure, and this slight material injury done by it, of
which we can see the growth and progress, the decline and
reparation in the eye ; may we take them as types representing
certain secondary inflammations and their eflects within the
body, which we cannot sec, but which, nevertheless, we treat as
inflammation, and readily seem to cure ? In short, may we
take them to represent what the unsoinid heart often suflers and
recovers from, when, upon fresh attacks of acute rheumatism, it
is affected in the manner described, and, being treated as if it
were inflamed, is relieved from its present excess of palpitation
and pain ?

Unquestionably, this is a very important class of affections
of the heart which we have been considering, and needing, from
the very default of precise diagnostic signs, that all their other
circumstances should be the more carefully examined. It is
most true that neither our eyes nor ears can testify what it is
we treat, or what it is we cure, but we treat and wo cure some-
thing. The clinical history of the jjatient, his previous con-
dition and his past diseases and all the incidents and appurte-
nances of his present attack, and especially the nature of the
remedies which procure his relief, are enough to show, even in
default of precise diagnostic signs, that we treat and cure a
secondary inflammation of the heart.

liECTc XX.] RENEWAL OF SKCOXDAKV INFJ.AAI.MA'riONS. 263

But secondary inflammation of the heart often shows itself
in such a manner as to constitute a class of cases intermediate
between those which were noticed in the fon)ier lecture and
those which liave been just described, more amenable to the
treatment than the first, and less so than the last. Like the
primary inflammation, it will often continue for some time af tei"
the rheumatism, or whatever be the coincident malady which
-seems to have reproduced it, has passed away, and still require
a special treatment to withhold it from a fatal termination, and
then, as in the primary inflammation, so in this after it is fairly
arrested, many weeks will sometimes elapse before the patient
is brought back to a state of present safety ; and then at last it
will be quite evident that something has been added to the
permanent unsoundness of the heart. The habitual palpitation
-and i^rajcordial uneasiness will now be found greater than they
were before, and having a greater amount of dyspnoea as their
•constant accompaniment ; and they will all, palpitation, and
pain, and dyspna?a, now show themselves capable of being
-aggravated uj^on slighter and more frequent occasions, and so
will place every action and movement of the bod}' under a more
severe and painful restraint.

When secondary inflammation has been thus a few times
renewed in the heart, and the patient, though his life be saved,
has reverted after each attack to a worse condition than before,
it is remarkable how little it takes to light it uj) afresh. A
rheumatic fever is sure to do it ; e\en a common febrile catarrh
may do it ; nay, it will sometimes appear to light itself up
spontaneously ; and thus with a cause or without a cause it will
return, or seem to return, at short intervals of months or weeks,
and the patient perhaps will at last die of an attack much less
severe than many a one that has preceded it.

The inflammation (I say) will return, or sce?n to return ; for
now, when the palpitation and the anguish of the heart and the
dyspnoea are constantly severe, we must not be too peremptory
in believing that every exasperation of them to a higher degree
of severity is caused by a fresh access of inflammation. Some-
:times mere rest will abate them, and sometimes rest with the
help of an opiate ; and all this looks very unlike inflammation,
but is far from conclusive that it is not inflammation. Some-
-times both rest and an opiate together will fail without the aid

264 CLINICAL MEDICINE. |_LECT. XX.

of leeches, and even of leeclics more than once applied ; and all
this looks vei-y like inflammation, but is far from conclusive that
it is inflammation.

Here, perhaps, I ought to go into the details of a score or
two of cases for confirmation of what I have been saying ; but
unfortunately they would need to be long details, and I dare
not venture upon them. The circimistances of half a man's life
may and have a bearing upon his present disease (they indeed
often have upon the secondary inflammation of the heart) and,
when you come to set them forth, you seem rather to be telling
a story than relating a case.

One such story, however, I must tell, as a specimen. It
will be found to contain a good deal to the purpose, and may
stand in the place of many. There was a certain j-outh, David
Aikin by name, and he was fifteen years of age ; he was a poor
puny lad, and first came under my care at St. Bartholomew's
Hospital, when he was suffering an attack of acute rheumatism.
The proper rheumatic symptoms were trifling, but there Avas
great pain in the pra?cordial region. The heart beats with an
excessive impidse, which was perceptible over a much larger
space than natural, and each contraction of the ventricles was
accompanied by a loud endocardial murmur.

The boy's father said that he had never been well since his
childhood. It was then that he was first ill of rheumatic fever,
which aflfected his chest, and thenceforward he liad always
siifiered palpitation, and shortness of breath. The palpitation,
however, and dyspnaa, were now much worse than usual ; and
this was the case upon every fresh attack of rheumatism which
he had suffered ; and he had suffered a great number.

On this occasion the proper rheumatic symptoms were soon
removed, but the pra)cordial pain, and the excessive impulse of
the heart were not abated, until, besides the apijlication of
leeches, a few ounces of blood were taken from the arm ; and
after all the impulse still remained far greater than natural, and
the murmur as loud as ever ; conditions which it was in Aain to
think of getting rid of altogether. And so in a few weeks he
left the hospital, with the same palpitation, and the same
asthma, as he called it, which he had had for years.

Some weeks after he was re-admitted into the hospital, suf-
fering great distress of respiration ; yet there Avas a clear

LECT. XX.] ('A8K OF .SKCONDAKV IN KLAMMA'l'ION. 260

respiratory murmur, unmixed Avitli crepitation, throughout
every part of the lungs. But the heart was beating most tumul-
tuously, and with a loud endocardial murmur. There was now
no rheumatism, and no accompanying fever. Merc quiet restored
him to a state of tolerable comfort, and he again left the
hospital without any change in the essential conditions of hh
complaint.

Some months afterAvards, happening to visit the Middlesex
Hospital, I was taken by Dr. Watson to see a case of diseased
heart, which he was watching with some interest, and I inmie-
diately recognised poor Aikin as the subject of it. He had
experienced another attack of rheumatism, which, as usual, had
greatly augmented all that the heart habitually suffered. The
rheumatism had now passed away, yet fever still remained, and
with it a severe praccordial pain. But the heart had almost
lost its endocardial murmur, and its impulse could hardly be
i'elt. It fluttered and faltered, and its contractions were all too-
weak to make its murmur clearly audible. He lingered a few
days longer, and then died, as if from exhaustion.

I was permitted to be present at the examination of the
body, and these were the most important appearances which
presented themselves. The cavity of the pericardium was
entirely obliterated by the most close and intimate adhesion :
the pericardium seemed one with the heart, no visible trace of
lymph any where remaining as the medium of their union,
except opposite the right auricle. And here, too, there was at
first an appearance of the same intimate adhesion of the-
opposite pericardial surfaces, with great augmentation of the
muscular substance, but, upon a section of the auricle, what
had seemed its proper muscular substance, was in fact found to
be coagulable lymph of the firmest, densest texture, half an
inch thick, and so deeply injected with blood as to have the
appearance of muscle. Beginning from this situation we were
able, not without much force, to separate the adherent pericar-
dium, and to detach it entirely from the heart. It was muck
thickened at every part, yet not, except opposite the right
auricle, by lymph heaped upon its surface, but by interstitial
deposition within its own texture. Its adherent surface, now
detached, was tolerably smooth, and of a deep red colour.

The muscular substance of the heart was unequally

•266 CLINICAL MEDICINE. [lECT. XX.

thickened, and one of its cavities only was dilated. On the
right side neither its muscular substance was thicker than
natural, nor its cavities of larger capacity. On the left the
auricle was neither thicker nor more capacious than natural, but
the ventricle was both by at least one-third. In every part of
the heart, both where it was thickened and where it was not,
the muscular substance was of the hardest and toughest texture,
and its colour of the deepest red.

The internal lining of the heart was universally of the same
deep red colour, and so was the lining of the aorta. The mitral
valve and the semilunar A'alve of the aorta, were a little
thickened and puckered.

A small quantity of bloody serum was found in both cavities
of the pleura, and on both sides there was a partial and slight
adhesion of the lungs to the ribs. The lungs w^ere full of
bloody serum. In parts they cut as if they w'erc solid ; but
still they were every w^here pervious to air, for every part
floated in water.

Now there is such a thing as reading disease backwards, if
I may so say. And a ver}' profitable method it sometimes is.
For itjading it in the ordinary way we may not have made out
the matter to our perfect satisfaction, and may have great need
of this retrospect to elucidate it. What I mean by reading a
disease backwards is, having its results before us and trying to
unravel their series and sequences, and so to interpret the time
of their occurrence and to assign them a relation to past events
of its clinical history ; to learn what took place last or yester-
day, and had a share in the process of dissolution, and what
took place earlier and had to do with antecedent attacks, and
what took place earlier still, and was the rudiniental change
which accompanied the first transition from health to disease.
In this way disease is traced back from its end to its beginning
by the prints or vestiges it leaves of itself during its progress.

The changes of structure, appertaining to the heart in the
case just related, Avere very numerous and complex, but their
meaning was construable enough. They were all reducible
to three distinct forms, those which arose last of all and at
the very end of the disease, and those which took place at
mid-periods, and those which came first of all and at its
beginnino-.

LECT. XX.] CASHOF SFX'ONDAK'V IXl"L.\M.MA'rLO\. 2G7

First, Ihci'o was tlio (loop rod 1in;2;o nt every part of tlio
organ, th(^ entire saturation witli iujoctod blood of all tliat
remained to it which could be called lu>allhy, and of all that
was added to it by disease. And tliis xiiupicstionably denoted
the closing eft'ort, the last worlc of disease within the blood-
vessels, bearing simultaneously with fatal force, both upon the
lungs and upon tlio heart ; and this was the immediate cause
of death.

Secondly', there was the great mass of hard tough lymph
encasing the right auricle, and the interstitial thickening of
the pericardium, and the remarkable induration of the entire
muscidar substance of the heart. And these were probably
the results of the several renewed attacks of inflammation,
each augmenting the heart's unsoundness, by adding some-
thing of the same morbid species to what there was before,
depositing fibrine upon hbrine, and interlacing it more and
more with the membranous and muscular textures, and so
spoiling them.

And, thirdly, there were the close union of the pericardium
with the heart at every part, except opposite the right auricle,
and the thickened and puckered mitral and aortic valves. And
these were probably the results of the earliest attack of peri-
carditis and endocarditis. The inflammation ceased and never
afterwards returned to the endocardium. The beads of lymph
were absorbed or thrown off from the valves, and where they
had been the surfaces were left uneven. But this amount of
injury which was done by the first inflammation was never
■afterwards augmented in the least degree. And the inflamma-
tion ceased too, and probably never afterwards returned to the
pericardium at the same part or after the same manner. The
serum and lymph were absorbed, and there followed a close
adhesion of its opposite surfaces, which nothing afterwards
disturbed.

All these several changes of structure found in a single
heart, which we have been commenting upon, were none other
than the immediate eflects of the first and of each subsequently
renewed inflammation, or rather the ver}^ Avork of the inflam-
matory processes themselves.

But there was yet something more in the same heart, some-

268 CLINICAL MEDICINE. [lECT. XX

tiling- noticeable enough but not to be particularly dwelt upon
in this j)lace, the augmented c apatity and augmented bulk of
the left ventricle. These were not the work of any inflam-
matory process. They were no disease in themselves, but the
romotei mechanical results of disease. Of such we shall speak,
hereafter.

LECT.XXl] UNSOilNDNHSS FKOM ENDD- AND I'l'.lilCARDITIS. 269

LECTURE XXL

THE UNREPAIRED EFFECTS OF ENDOCARDITIS AND PERICARDITIS
BOTH CONSTITUTE A PERMANENT UNSOUNDNESS OF THE HEART
IN THEMSELVES, AND BECOME THE POSSIBLE ELEMENTS OF

FURTHER UNSOUNDNESS BEYOND THEMSELVES. THE SAME

MAY BE SAID OF THE I'NREPAIRED EFFECTS OF OTHEPi.
DISEASES. — THIS FURTHER UNSOUNDNESS A THING DIFFERENT

IN KIND. NATURAL DISTINCTION BETWEEN THE UNSOUNDNESS

FROM DISEASE, AND THE UNSOUNDNESS FROM DISORGANISA-
TION. SUMMARY ACCOUNT OF THE UNSOUNDNESS FROM

ENDOCARDITIS ; COMPARED (bY ANTICIPATION) WITH THE
UNSOUNDNESS FROM OTHER DISEASES OF THE ENDOCARDIUM.

It has been already said, that when the heart is left in a state
of unsoundness by past inflammation, whether of the endocar-
dium, or of the pericardium, or of both, two principal conse-
quences are to be expected. Either there may be a renewal of
inflammation in the unrepaired structure, or in some other
structure, of the same heart ; or the unrepaired structure,
remaining as it was left, may become the element of further
material changes in the whole organ. The first of these con-
sequences has been considered alread3^ The second remains to
be considered.

Now this last is much the more frequent of the two. The
first, i.e. the renewal of inflammation in the unsound heart,
happens comparatively to few. For it is, as we have remarked,
of the nature of an accident, and dependent on circumstances
befalling the individual. But the further disorganisation of
the heart, growing out of the elementary unsoundness left by
inflammation, certainly hajjpens to the vast majority, and, if
accurate measure could be taken during life, of all its degrees,
would probably be found to happen almost to all. For it
springs, as we have remarked, from a natural and inevitable
tendency. Wherever there is unsoundness of any elementary

270 CLINICAL MEDICINE. [lECT. XXI.

tissue from disease, further unsoundness is (I believe) almost
sure to follow sooner or late from disorganisatioit. Different as
the}^ are in tlieir nature, tliere is a link of connexion between
them. The first is a chief orio^inatino: cause of the second.
Therefore, in passing from one to the other, we do not violate
but rather preserve the context of our subject.

I know not whether these terms, im soundness from disease
and unsoundness from disorganisation, be the best that could be
chosen to express my meaning, but, as I shall often hereafter
make use of the same, it would be well for me to state briefly
what I Avish to be understood by them.

Already, a good deal has been intimated respecting the
unsoundness from disease, but nothing yet respecting the un-
soundness from disorganisation. In distinguishing between
them, we must try first to get a right notion of what each is in
its own nature, and then to make good the link which connects
them.

Now they may be characterised generally after the following
manner. In both there is a material detriment done to the
natural structure of the heart. AYhen the unsoundness is from
disease, the detriment is of the same kind which the same
disease, be it what it may, whether inflammation or struma or
cancer, would produce in every other part of the body. But
where the unsoundness is from disorganisation, the detriment
is of a kind proper to the heart itself, and such as never does,
and never can, take place in any other organ of the body.

Again the unsoundness from disease is made up of new
substances which each disease produces according to its kind,
and which are difierent from the natural and healthy substance,
and are superadded to it or are substituted for it : or it results
from a simple destruction of the natural and healthy substance.
But the unsoundness from disorganisation consists in alterations
of bulk and size and shape and capacity, no other causes being-
engaged in bringing them about than those which are con-
stantly at work within the healthy heart, viz. its own vital
movements ; only they are now at work with more or with less
energy than is either natural or healthy, or they are at work
without their natural and healthy harmony.

But what is it that [^can rouse the vital movements of the
heart to a greater energy than natural, or subdue them to a less.

LECT.XXl] UNSOUNDNESS FROM ENDO- AND I'llU'H AUDI TIS. 271

or can distuvl) their natural harmony? It must bo something
within or without the heart amounting to a physical necessity.
When it is Avithin the heart, the previous injury of some of its
elementary tissues from disease is that necessity. And hence is
formed the link of connexion between the unsoundness of
disease and the unsoundness of disorganisation. When it is
without the heart, the ailments or injuries of other organs
originate the necessity, and then convey it through the va scular
system or the nervous system, and. so make it felt in and by the
heart. Let this serve for a brief sketch of what is meant patho-
logically by the heart's unsoundness from disease, and the
heart's unsouncbiess from disorganisation, and the essential
dilierences which separate them.

But our business is first with the unsoundness of inflamma-
tion. For we are pursuing endocarditis and pericarditis to their
consequences. JN'overtheless, we must follow the subject as it
naturally expands itself, and be careful of handling it too ex-
clusively. Inflammation, as to the manner in which it fur-
nishes the element of disorganisation, illustrates the operation
of every other disease which is also capable of furnishing it ;
and every other disease illustrates the operation of inflamma-
tion in the like respect. And for this very reason thev mnstbe
considered together.

Well then, has all been said that need be said of this struc-
tural unsoundness of the heart in both its kinds pathologically^
and may we now proceed at once to clinical history, and clinical
diagnosis and treatment ; to what these things are and whence
they come and how they show themselves and what they need
and what they will bear in the living man ■ Let us j^ause awhile
and consider ; for if any further explanations of a general sort
be needed preparatory to a just comprehension of what is to
come, this is the place for them. And I believe they are needed. '
Such explanations now given will save us much time and many
words and many a troublesome digression. For this structural
imsoundness of the heart in both its kinds brings us to that
class of its affections, before announced,* which are " secret and
chronic in their growth and unalterable and irremediable in
their nature." And I have already promised to beware of
treating tliem too much at large.

* Patre 54.

272 CLINICAL MEDICINE. [lECT. XXI.

But it is the knowledge of their /in'ng forms that we espe-
cially desire to be conversant with. And this knowledge is not
41 whit the less pathological, because it is pre-eminently prac-
tical. Yet I cannot manage to display it as clearly as I could
wish without first entering into details which are pathological
in the stricter and more technical sense ; without first asking of
morbid anatomy what it has to tell of the effects of inflamma-
tion within the heart when they have become permanent from
a failure of perfect reparation, and of its effects both permanent
and cumulative from several accessions of inflammation and
from several failures of perfect reparation ; and also of the
effects of other disease within the heart, which is not inflamma-
tory ; and further what it has to tell of alterations of size and
bulk and shape and capacity in the heart. The former will
include all that matenalhj belongs to unsoundness of the heart
from disease in its several degrees from the least to the greatest ;
the latter all that matenaJly belongs to its imsoundness from
disorganisation in its several forms from the simplest to the
most complex.

Still I am not going to give an inventory of a whole museum,
but only to choose the fittest specimens to represent the kind of
thino-s with which we have to do, and the fittest to mark their
reality, a reality, which now, when we are approaching those parts
of our subject which we must be content to generalise, will often
need to be borne in mind, that it may keep us to tangible points
and withhold us from running oft into mere speculation.

It has appeared that out of sixty-three cases of endocarditis,
reparation was perfect in seventeen : for in them the murmur
ceased entirely. And that reparation was imperfect in forty-
six, for in them the murmur continued while life was safe for
the present.* But it is not from these forty-six cases that I
must draw my information of the nature and effects of an un-
sound endocardium, but from those which I have casually met
with in the course of j^ears.

By the description already given of the damage which endo-
carditis is capable of doing, it has been seen how great it is in
some cases and how small it is in others, and consequently how
much is left for reparation to effect in some and how little in
others, whether the result be the restoration of the membrane

* Page 88.

LECT.XXl] IINSOUNDNKKS FllOM KNDO- AND l'KiM(;Al»'l)lTI.S. 27^

to perfect soundness, or only the diminution of its unsoundness
to a deg-reo compatible with life. ( )ur present business is with
the latter result.

In looking over such records us I possess, of dissections
made where death had taken place at various periods of many
months or of many years after the attack which did the original
detriment to the endocardium, I find that the morbid appear-
ances may be reduced to a few, to opacity and thickening of the
membrane, to marks of perfect and imperfect cicatrisation, and
to breach of surface or solution of continuity.

The opacity and thickening vary much in their extent.
Some times they are confined to u single valve or to j)art of one
only, to its free edge; sometimes they aft'ect more than one,
genera lly two, the mitral and the aortic calves ; and they occa-
sionally extend to the valves of both sides of the heart, and
pervade both their proper membranous expansions and the
tendinous cords proceeding from them. Further, this same
opacity and thickening belong sometimes to other portions of
the endocardium beside those which form the valves and their
appurtenances, especially to the lining of the left ventricle
nearest the aorta and to the whole lining of the left auricle.

Beside such general opacity and thickening a particular
valve sometimes presents a hard elevated line or ridge where it
is especially thickened, or a small spot where it is indented or
depressed, looking like a complete cicatrisation in one case and
an incomplete cicatrisation in the other.

Sometimes a valve is perforated or cribriform or it wants a
portion at its edge, or a tendinous cord is snapt in two and its
ends are hanging loose Avithin the cavity of the ventricle.

If this be a true sketch of the heart's permanent unsound-
ness derived from the imperfectly repaired efiects of endocardial
inflammation, and this its different extent, and these its several
forms, and these its situations in different cases, you will see
that the blood must thenceforward always encounter some im-
pediment in its passage through the heart. And you will see
too how various must be the amount of that impediment, how
in one case it must be great and in another next to nothing, and
you will be prepared for the various fate of those who owe the
first damage of their heart to a rheumatic endocarditis.

All this is obvious enough. But belonging to the same

18

274 CLINICAL MEDICINE. [lECT. XXI.

district of pathology there arc certain conditions wliicli are less
obvious and which, as far as I know, have never been noticed
at all, but which I desire particularly to insist upon, on account
of their great practical importance. Indeed they need to be
pointed out as lights and signals to steer by, when we come to
contemplate, in the living man, the effects both immediate and
remote of the heart's unsoundness dci-ived from endocardial in-
flammation, and vfhen we are required to treat them and to give
opinions about them.

This then I believe to be a fact which, if not true in every
instance without exception, is true in the majority, viz. that,
after inflammation of the endocardium has ceased, and repara-
tion has done its best, and all that is reparable is repaired,
whatever remnant of unsoundness bo left, it continues ever
afterwards without increase in its oicn hind. After the lapse of
years the very appearance of all we find seems to testify that it
has long been stationary. There is no vestige of changes
recently in progress, no new growths mixed with old growths ;
each cicatrix is an old cicatrix, each perforation an old perfora-
tion ; all looks as if it bore the same date, and had been brought
to pass simultaneously. And hereafter, when the results of
clinical observation are compared with those of morbid anatomy,
they will be found to testify the same thing.

The unsoundness left after endocardial inflammation remains
(I say) without increase in its own hind. What is thickened
does not go on to be thickened more and more. What is cica-
trised does not go on granulating. Perforations and breach of
surface do not become larger and larger. All this I suspect
could only come from a renewal of inflammation in the endo-
cardium. But inflammation naturally comes to an end, and
when it has once ceased, there is not, I suspect, any natural
principle of growth in the things which it leaves behind enabling
them to increase of themselves. And herein inflammation and
its effects will be found contrasted with other diseases of the
endocardium and their effects, such I mean as produce deposits
of cartilage, atheroma, and bone. Here either the diseases do
not naturally come to an end, or their effects have a natural
power of growth within themselves. For cartilage, atheromn,
and bone go on increasing indefinitely. No doubt great struc-
tural damage is sometimes involved in the unsoundness which

I.ECT.XXl] UNSOUNDNESS FROM lONDO- AND PERICARDITIS. 275

Tcraains after a single attack of endocarditis. But upon the
■whole it is not apt to be carried to an extreme degree. When
an orifice of the heart has undergone extreme stricture, when
the mitral orifice for instance has been so narrowed as not to
admit the passage of a finger, I have commonly found that the
clinical history of the case has not assigned its beginning to
any certain period or to any known attack of inflammation ;
but it has testified on the contrary that the symptoms referable
to the heart arose and increased covertly and gradually, until
they reached an intolerable amount. The utter detriment and
'-poiling of the valve appertaining to the orifice, and causing its
extreme stricture, is not the stationary remnant of unsoundness
left by an attack or two of accidental inflammation, but the
progressive growth of unsoundness built up by a never-ending
chronic disease.

Further, it has already been stated, as a very general fact,
that the louder the endocardial murmur the less is the amount
of valvular impediment. Now, in almost all cases where the
heart's unsoundness is traceable back to an attack of rheumatic
endocarditis, the murmur is apt to be peculiarly loud. In such
cases then the inference would be, that the valvular impediment
is not great. It is remarkable moreover that the instances
which have furnished me the proof of this fact — of the louder
the murmur the less the impediment — have been chiefly where
the heart-affection has originated in acute rheumatism.

But be it remembered, that a further mischief to the heart
is always expected to follow the imperfectly repaired injury or
remnant of imsoundness left by endocarditis. But it is a mis-
chief different in kind, another sort of injury altogether ; it is
the unsoundness of disorganisation grafted upon the unsound-
ness of disease. This will be considered in its turn.

276 CLINICAL MEDICINE. fLECr. XXII

LECTUHE XXII.

CONSEQUENCES TO LIFE AND HEALTH FROM THE PERMANENT
UNSOUNDNESS OF THE HEART REMAINING AFTER ENDOCAR-
DITIS. 1. CASES IN WHICH BESIDE THE PERMANENT ENDO-
CARDIAL MURMUR THERE IS NO OTHER SYMPTOM REFERABLE
TO THE heart; 2. CASES IN WHICH BESIDE THE MURMUR
THERE IS OCCASIONAL PALPITATION ; 3. CASES IN WHICH
BESIDE THE MURMUR THERE IS CONSTANT PALPITATION.

Having considered tliat form of permanent unsoundness of tlie
heart, "whicli consists in the unrepaired effects of endocarditis,
we are prepared to pass from the nature of the tiling itself to
its living consequences.

The endocardial murmur having become permanent, and
denoting (as it undoubtedly does) permanent injury of some
portion of the endocardium, it becomes most interesting to
enquire what follows ; what detriment either immediately or in
process of time results to the health and well-being of the
patients. In some no detriment whatever immediately results.
Together with the permanent endocardial murmur they suffer
neither pain nor palpitation nor any sort of distress or embarrass-
ment referable to the heart under any circumstances. Their
disease is no affair of their own consciousness. The physician
hears something but they feel nothing ; they believe themselves
well, but the physician knows that they have an injured portion
of the endocardium.

Now the severest and the mildest cases of endocarditis have
equally this termination. The fever, pain, and swelling of the
joints, may have been excessive, and anguish and distress of the
chest and palpitation and fluttering of the heart may have kept
life in jeopardy for many days. But these may all pass away,
and nothing remain except the endocardial murmur.

Or the fever, pain, and swelling of the joints may have been
barely enough to characterise the disease, and there may have
been no symptom, either pain or anguish or palpitation or

LECT. XXII.] im:ijmani:nt endocardial murmur. 277

fluttering, wliicli could denote that the heart had any share in
it, save only tlie endocardial murmur. But this never ceases.

Here then is a certain injury of the endocardium, which the
heart bears patiently and unconsciously, neither feeling it nor
resenting it for the present. But what in process of time is the
event of such cases r*

You maj^ think perhaps that my experience should be ample
enough to tell you all that can be known concerning them.
But indeed it does not reach so far in this matter as you might
at first suppose. It is true that I have witnessed the original
disease in a great multitude of individuals, and I have seen its
symptoms dwindle down to the single one in question. But the
vast majority of those discharged from the hospital still bearing
this symptom have escaped entirely beyond my observation, and
I have never seen or heard of them more.

Some however have again fallen in my way, and thus I have
been able to pick up certain particidars of infornuition which it
may be useful for you to know.

It has not unfrequently happened to me, when I have been
examining patients at the hospital, to find the marks of former
leech bites or the scarifications of cupping glasses upon the
precordial region ; and this circumstance, and not any com-
plaint of their own in this quarter, has led me to apply my car
to it, and thereupon I have discovered the endocardial murmur.
Inquiring when and why it was they had need of leeches or
cupping to this part, I have learnt from them that it was when
they had a rheumatic fever, and because at that time something
was the matter with their heart. But this happened years ago.
They got well, and from that day to the present they have
remained without palpitation, or shortness of breath, or any
inconvenience whatever referable to the heart, which they were
at all conscious of. ,,

In these individuals there can be no doubt that the condi-
tion of the endocardium, which now gives occasion to the mur-
mur, had its origin in inflammation coincident with the attack
of rheumatism to which they refer. Indeed some of them I
have recognised as having been my own patients, and turning
to my record of their former malady I have found the fact to
be just as they have stated it. They suffered acute rheumatism
in the course of which the murmur arose. The rheumatism

278 CLINICAL MEDICINE. [lECT. XXIL.

ceased but the murmur remained, and they finally left the hos-
pital carrying with them the still audible murmur. Between
the origin of the murmur dated from the attack of acute rheu-
matism and the present time when it is found stiU to continue,
there has been in the several cases an interval of one, two, three,.
four and five years, and in the meanwhile the patients, most of
whom have been engaged in occujDations needing bodily exertion,
have been unconscious of aikncnt.

The cases in question convey this piece of consolatory in-
formation, that while there is no doubt to what disastrous
results the injury of the endocardium naturally tends, it does
not go on at once and of necessity to produce them, but that,
between the elementary morbid process and the results which
are most expected and most feared, there may be a suspense of
years. For even under the unfavourable conditions which
belong to a life of hard bodily labour, such permanent organic
changes of the endocardium as are left by acute inflammation
and denoted by the murmur may exist for five years without-
the least consciousness on the part of the patient, that he has
any disease of the heart.

But what is the actual condition of the heart in such cases ?
AVTiatever was the condition in which it was left after the
original attack of acute rheumatism, the same (there is reason
to believe) is its condition now. The physician then heard the
murmur, and now after the lapse of years he hears the same, but
discovers nothing more ; and so he has no grounds for believing
that further detriment has arisen to the organisation of the
heart even after the lapse of years. He knows that there is an
injured portion of the endocardium but he knows nothing more.

Now where the heart bears the injury of its endocardium
thus patiently for years, it is fair to infer that that injury is either
so small or so fortunately placed, as to ofter no sensible obstruc-
tion to the passage of the blood. A little ridge on the surface
of a valve, a little granule on its free edge, or a little thickening
or sjiortening of a tendinous cord, may be conceived capable oi
occasioning eddies and vibrations of the blood which can bo
heard, without producing any hindrance of its current which
can be felt.

Of all those who suffer rheumatic endocarditis and recover
but with some permanent detriment done to a portion of the

LECT. XXII. J PEKMANENT ENDOCAKDIAL MUKMUK. 279

c^ndocardium, aiarge proportion, I suspect, full under the fore-
going description.

This fact then is ascertained and coutirmcd by experience,
viz. that the damage done to the endocardium by rheumatic
inflammation may abide for four or five years without producing
any conscious detriment to the health or well-being of the
patient, or (as far as we have the means of judging) any
farther injury to the structure of the heart. And it is a most
important and consolatory fact. But in other instances other
results immediately follow. When after its departure acute
rheumatism leaves the endocardial murmur behind it, which,
though known only to the physician, is the sure sign of injury
done to the endocardium, it leaves it attended from the be-
ginning by other symptoms, which the patient is sufiiciently
conscious of, and these are directly referable to the heart.
They consist of palpitation, and some pain, and some dyspnoea,
which are not constantly present, but only under bodily exer-
tion and mental excitement. The child who has had the
praicordial murmur ever since it suffered a certain rheumatic
attack, is just the same child it was before, except that it
cannot join in any pastime requiring rapid movement : for
then its heart palpitates, it loses its breath and is obliged to
sit down. Men too are just the same men they were before,
only perhaps they cannot run upstairs without panting and
hurry, and they constantl}" find themselves obliged to restrain
their bodily efforts within certain limits, and to beware of
mental excitement, for fear of palpitation and dyspna-a.

These conditions too may remain for years without either
augmentation or abatement. The murmur is never absent, but
the palpitation and dyspnoea arc never present except as the
immediate efiect of a certain amount of bodily exertion or
mental excitement.

Among the cases of rheumatic endocarditis whose history I
have investigated, the instances have been very numerous in
which I have found a space of from one to five years imme-
diately succeeding the original attack exempt, according to the
patient's own account, from all ailment except an occasional
palpitation and dyspnoea. This exemption however has been
favoured by peculiar circumstances, by a daily occupation not
requiring bodily labour and free from the greater cares and

2S0 CLINICAL MEDICINE. [lECT. XXII.

hardships of life. The patients have been men of sedentary
professions or they have been young people, the children of
parents in easy circumstances. I have lately seen a young
lady thirteen years of age, whom I attended three years and
a lialf ago under an attack of acute rheumatism attended by
endocarditis. The symptoms during the attack referable to
the heart wore completely characteristic of the disease, and
carried to such extremity, as to keep life in peril for several
days. It was perhajDS the severest case I ever saw recover.
She did recover, however, but never lost the murmur and
occasional palpitation. At present she has the appearance of
perfect health. She even bears the marks of premature woman-
hood. She goes to school, plays about like other girls, but
cannot run so fast or so far as the rest or use bodily exertion
beyond a certain amount without dyspnoea and palpitation, and
some pain in the region of the heart. For all other purposes
she is absolutely well. In examining the state of her heart
when she is quite free from all excitement, I find no extra-
ordinary impidse, either of extent or of degree. It is felt only
at the apex, Neither do I find any extraordinary extent of
dulness to percussion. A systolic murmur is audible every-
where within the pra^cordial region, most audible at the apex,
more faintly at the basis. From the basis upwards towards the
right clavicle in the course of the aorta and subclavian artery
it is entirely lost, towards the left clavicle aiid in the course of
the pulmonary' artery it is very loud, but not at all heard in
the carotids. From the apex the murmur extends far round
towards the left axilla and the back. Here I presume that the
rheumatic inflammation has done a pennanent injury to the
endocardium on both sides of the heart, and that the mitral
valve and the semilunar valve of the pulmonary artery have
undergone change of structure.

I have already said that I have known numerous instances
of a permanent endocardial murmur, which had its origin in
an attack of acute rheumatism, existing for various periods of
from one to five years, without any consciousness of ailment
excef»t at times of bodily and mental excitement. If the-
patient's own testimony may be taken to fix the origin of his
disease (and there is no reason why it should not), I have seen
one instance where these conditions existed for 20 years. A

•LECT.XXII.] MURMUK WITH rALPITATION AND DYSPNCEA. 281

clergyman, 39 years of ago, worn out by the cares of lils
parish, pale, and thin, came to me, and veconnted a long cata-
logue of nervous distresses, lie complained too of palpitation
of the heart upon any great bodily exertion, or mental excite-
ment, and after stimulant food. And this palpitation I thought
would turii out to be nervous too ; but auscultation found the
loudest endocardial murmur at the apex, and at the basis of
the heart, and in the carotid arteries. I fancied there was also
.a slight excess of impulse, but of this he himself was unconscious
.•at the time, and said he never felt it when quiet, as he then
was. Percussion discovered no unnatural extent of dulness in
the proccordial region. In truth I was sure of nothing extra-
ordinary iippertaining to the heart but the murmur.

Now this gentleman reported that once in his life, twenty
years ago, he had suffered an attack of acute rheumatism ; that
his heart was said to be affected at the time, and he had reme-
dies applied to it, and that from that day to this he had ever
been liable to palpitation, not constant, but occasional only, and
the inevitable consequence of excitement.

Thus we have been contemplating two conditions which are
the result of rheumatic endocarditis ; one in which there is a
permanent murmur, without the least consciousness of ailment
on the part of the patient under any circumstances, and with-
out the least evidence furnished to the physician, from auscul-
tation, of further detriment done to the heart (beyond the
original injury of the endocardium) after the lapse of years.
The other in which there is a permanent murmur with palpita-
tion and dyspnoea which are occasional only, yet inevitable
upon a certain amount of excitement, and still without the
least evidence of increasing detriment to the heart, even though
years had passed since the original injurj^ of the endocardium.

What then is the essential difference between these two
orders of cases ? It is probable that the difference rcsjiects
only the degree of injury sustained by the endocardium. This
is not great in either case ; but less in the hrst, whore it is
•enough to produce an eddy of the blood and a vibration among its
particles, and a consequent unnatural murmur, yet not enough
to occasion such a sensible obstruction to its current as the
heart either feels or resents ; and greater in the second, where,
under ordinarv circumstances, it is still not enough for the

282 CLINICAL MEDICINE. [lECT. XXII.

lieart eitlier to feel or to resent, but, wlieii an occasion of
accelerated motion arises, it both feels it and struggles against
it as an obstacle.

There is yet another description of cases, including those
who have a ijermanent murmur derived from acute rheuma-
tism, and together with it a permanent palpitation. After the
subsidence of the rheumatic attack, the patients may recover
the aspect, and many of the feelings and functions of health ;
but their heart is always found to beat with somewhat more
than its natural force, and with very much more upon any
considerable exertion. Now, from this palpitation, conjoined
Jro'Di the fird with the permanent murmur, I do not know that
we can justly infer that the heart has sustained from the Jint
a detriment to its structure beyond the injured endocardium.
But in such cases, Ave are apt to think that we shall not have
long to wait for the authentic signs of its more extensive dis-
organisation, and we are apt to look for an earlier incaj)acity
and an earlier death. Yet this need not be : oven here the
changes for the worse are often very slow. Life, useful and
enjoyable life, may endure for years, even (as the following
case will show) for twenty-two years, and then afford the
prospect of enduring still.

A lady thirty- six years of age, thin and pale, was brought
to me by a medical man for consultation upon all the circum-
stances of a very long abiding malad3\ The impulse of her
heart, always excessive, was avigmented to violence upon any
exertion. She suffered dj^spnoca when she moved about, but
no cough, and no expectoration, except on occasion of an
accidental catarrh. Her bowels were regular, and other
functions were proceeding naturally. On examination of the
chest, the lungs were found to admit air freely. The heart was
felt beating at every part of the pra;cordial region, and an
endocardial murmur accomjianying its systole was heard at the
basis, and thence becoming louder and louder as it was con-
veyed downwards towards the apex, and feebler as it was con-
veyed upwards in the course of the aorta. It ceased abruptly
before it reached the subclavians, and was inaudible in the
carotids. It was loud in the left axilla, and everywhere in the
back below the scapula;.

Now what was the historv of this case ? At the aj>e of

LECT.XXII.] MlJKMUii wmi PALPITATION AM) DVrtP\(EA. 28o-

fourteen this lady had an attack of acute rheumatism, and she
jicrfectly recollected the palpitation whicli she then suffered,,
and the remedies Avliich were addressed to lier chest. From
that time forth her chest had never been at ease. At the age
of eighteen she had a second attack of acute rheumatism, but
the habitual symptoms referable to the heart wore neither
aggravated at the time nor rendered permanently worse after-
wards. Ten years ago she had a third attack, which for the
time brought upon the heart an extraordinary amount of
suffering, but left it no worse than it was before.

This lady married at thirty. She had had one living child
and several miscarriages. She bad suffered a miscarriage nine
weeks before I saw her, with considerable hemorrhage, and
from that time her palpitation had been unusually severe.

I enjoined perfect quiet, and recommended that her nervous
system should be kept constantly under the soothing influence
of paregoric and ammonia.

I saw her a few weeks afterwards. She had lost her pale
distressed look ; and herself and her medical attendant both
declared that what she then was might be taken to represent
her habitual state. All the unnatural sounds of the heart,
which I had foimd before, still remained, and nearly the same
excess of impulse. I considered that the mitral valve was
unsound, and that the left ventricle was in a state of hyper-
trophy and dilatation, and the aortic valve not altogether
uninjured.

Taking then the three descriptions of cases in their order, 1
believe it to be the tendency of each to pass progressively
onward into the others. The endocardial murmur left by acute
endocarditis may be simple and alone, and so it may remain for
years, but it is ever apt to have a palpitation added to it. The
palpitation accompanying the murmur may be occasional only,,
and so it may continue for years ; but in the mean time, it is
ever ready to become permanent. The permanent palpitation
may remain for a while moderate in degree, but it is always
tending to become greater and greater. Of these three con-
ditions, then, the best that experience allows us to hope is, that
each may remain stationary ; for their changes are never retro-
grade, but always progressive and always for the worse. Each
condition becomes worse as it is converted into the other, and

284 CLINICAL medicinp:. [lect. xxil

tlie condition of permanent palpitation passes on to new results,
jind to the final and fatal event.

The nature of these results -will be considered hereafter.
In the meantime, remember the important fact which clinical
experience has just been brought to testifJ^ It is this — that
the evil consequences to life and health arising out of the heart's
permanent unsoundness left by endocarditis are often either
stationary at a small amount for years, or very slow to advance
and accumulate. If a reason of the fact be asked, it will be
found in the stationary and unincreasing nature of the original
endocardial unsoundness.

LECT. X.VKI.] INSOUNDNESS l-'SJOM I'KlilCARDITIS. 28-7

LECTURE XXIII.

TKUAIANENT UNSOUNDNESS FROM PEKICAKUITIS ; ITS MANY 1)!:-

GREES ; SOME HARMLESS. GENERAL VIEW OF THE EFFECTS

OF PERICARDITIS AND OF THEIR REPARATION. HOW ULTI-
MATELY INCOMPLETE AND ENDING IN PERMANENT UNSOUND-
NESS OF VARIOUS DEGREES. SOME OF THEM SPECIFIED AND

COMMENTED UPON. CUMULATIA'E UNSOUNDNESS FROM SEA'ERAl .

ATTACKS OF PERICARDITIS.

When pericarditis has ceased and life is safe for the present,
auscultatoiy signs cannot be appealed to for information resj^ect-
ing- the state in which the pericardium is left, as they were after
endocarditis respecting the state of the endocardium. The per-
fect or imperfect reparation of the pericardium cannot bo
inferred from the entire cessation or the permanent continuance
of the exocardial murmur. In truth there is no such thing
known (I believe) as its permanent continuance. If life go on,
its cessation must follow, whether the pericardium be restored
to perfect integrity of structure or not. Being perfectly
restored, the healthy surfaces Avould again glide upon each
other freely and without sound. Being imperfectly restored,
the unhealthy surfaces A^^ould adhere and so abolish the sound
which had resulted from their friction. A stop is put to the
murmur in both cases, and its cessation proves nothing in either.

From the description already given of the damage which
pericarditis is capable of doing, its amount will be seen to vary
greatly in different cases. Accordingly, reparation has much
or little to do in different cases before it reaches (I will not say)
perfect soimdness, but that degree of diminished unsoundness,
which makes life safe for the present. It is with the last that
we are now concerned.

So much of the effects of pericarditis, as, after they have
admitted reparation to the utmost degree of which the}' arc
capable, is still found to remain permanently and unalterably^

286 CLINICAL MEDICINE. [lECT. XXIII.

this it is which in each particular case, be it more, or be it less,
constitutes the unsoundness.

But when reparation has done its best, how much is
actually found to remain ? More or less in different cases, but
something, I suspect, in all. I am disposed to take it for a
fact, that whenever inflammation of the pericardium has been
enough to declare itself by symptoms, the detriment done never
undergoes perfect reparation ; the pericardium never regains
its integrity of structure, never, in short, again becomes what
it was before it was inflamed. And in as far as it falls short of
it, so far, it is permanently unsoxmd ; and this may be very
little, or very much.

What then is the nature and what may be the degrees of
the heart's permanent unsoundness derived from the partially
repaired effects of pericardial inflammation, now come to be
considered ?

There are often found after death, where thej'- have been
unsuspected and unloohed for during life, small adhesions of
the pericardium, of which the heart never felt the injury, the
result of some slight attack of inflammation of which it never
felt the presence or the pain. They consist of long loose bands
running between the heart and the pericardium, or of a few
slender threads between the pulmonary artery, and the aorta.
Some of these Mr. Paget never fails to discover, wherever there
are white spots upon the heart, and from the coincidence of the
two, he has drawn the sound conclusion that both are the effect
of inflammation; inflammation however, of which there are
commonly no traces in the history of men's lives,' to match these
sure and authentic ones met with after their deaths.

Here the unsoundness, which consists in the adhesion, is of
the least possible degree. Yet unsoundness it must still be
called, unfelt as it is and harmless ; for it displays the effects
of a by- gone inflammation imperfectly rej^aired. But I can
make no use of these cases practically.

Again, there has been sometimes found after death, where,
during life, nothing has given the least suspicion of its existence,
one universal adhesion of the pericardium, and its cavity
entirely obliterated. I have myself known a few such cases.
No symptom during life has pointed to the heart and the dis-
ease that immediately killed the patients has belonged to other

LECT. XXIII.] lJNSOUNDNIvS.S FIIOM IM:K'ICA!v1)IT1S. 287

organs. They have however been casual cases, and I had no
acquaintance with the conditions of the patient's death, prior
to their fatal illness. My observation of them had only been
during the last few weeks of their existence, when, if ever, a
damaged organ is apt to betray the secret of its unsoundness.
I Jut even then, the heart had escaped my suspicion, and after
death it disclosed what I never looked for. The cavity of the
})oricardium has been entirely obliterated by adhesion. Further
the adhesion has been effected with the least, or with hardly
any, apparent medium of adventitious substance. And, further
still, the muscular structure of the heart has been neither
thickened nor attenuated, nor any of its chambers unnaturally
large or small. Except the complete adhesion of the pericar-
dium and the obliteration of its cavity, the heart has been
altogether normal and healthy,

!Now these cases I can indeed turn to a practical use. I
find in them the explanation how it sometimes comes to pass,
that the most acute pericarditis has its termination, not merely
in present safety, but also in (what, at least during life cannot
bo distinguished from) perfect health, I have known a few
cases, and a few others have been credibly reported to me, of
individuals, Avho having suffered an unequivocal attack of peri-
carditis, have, after the lapse of some months, betrayed not the
least evidence of an injured heart, and who, in every feeling
and function of their bodies, have been as perfectly well as ever
they were. But in these cases did the pericardium recover its
perfect structure, and were its surfaces everywhere ununited
and freely moving iipon each other again ? I doubt whether
this be possible. Or did the pericardium contract a complete
and permanent adhesion to the entire obliteration of its cavity,
and that by the least conceivable quantity of adventitious
lymph ? I know that this is possible from the cases to which
I have referred, and I know too, although it be a state of
imperfect reparation or unsoundness, yet that it is compatible
Avith the perfect functions of the organ, and need not lead to
its further disorganisation.

Take one case in illustration.

Louisa Hawkins, a young married woman, twenty years of
age, was admitted into St. Bartholomew's Hospital, on the 23rd
of June, 1836, suffering from acute rheumatism. Almost all

288 CLINICAL MEDICINE. [lECT. XXIII,

her larger joints were swelled, and red, and painful, and bad
been so for tbree days ; ber left side, too, was painful, and sbe
bad sbort breatbing and a drj^ eougb ; and witbal ber beart
beat witb a genuine exocardial murmur. Her fever ran very
liigb, and ber disease altogether was very severe. Sbe was
treated by cuj)ping and leecbes, and by calomel and opium.

The exocardial muimur preserved its distinctive character
for five days ; and tben for five daj's it was sometimes present
and sometimes absent, and varied in different postures of tbe
body, and tben it went away altogether, and left the sounds of
the heart perfectly healthy and natural. It took a fortnight
from the patient's admission to bring ber disease to a close ;
and then sbe remained three weeks longer under our observa-
tion receiving"[sucb help from medicine as her weakness and her
shattered nervous system required. At the end of five weeks^
she was still weak but gaining strength daily, her heart beating
with unnatural frequency but without the least unnatural
sound.

This Avas considered to be a case of simple pericarditis, very
severe in degree, but arrested by active treatment before it had
gone on to produce a large accumulation of lymph. Hence
severe as it was and severe as were its remedies and great as
was the constitutional suffering, the actual detriment done to
the heart was probably not large and the powers of reparation
were not highly taxed.

In the month of February, 1837, this young woman came
to the hospital to paj^ a visit of gratitude to the sister of the
ward. I saw her. She was the picture of health. She told
me that she soon recovered her wonted strength after she left
us and that she had been unconscious of the least ailment ever
since, and that there was nothing in the way of bodily exertion
which she could have done before her illness that she could not
do now. After the most careful auscultation bestowed upon
her heart by myself and others we could find no fault with it.
Its contractions, sounds, and impulses w^ere rhythmical, healthy,
and natural, and the pra^cordial region afibrded its due resonance
to percussion. — (W. 21, 33.)

This is indeed an encouraging case. Hero was no slight or
covert or doubtful disease, but one having a sure living diagnosis,
a manifest pericarditis, acute and perilous and depositing lymph

LECT. XXII [.] UNS0UN1)M:S8 from PERTCAIv'nrTTS. 289

upon the surface of the lieait. It was treated as sucL, and its
syinptoras were abolished and life was saved for the present.
JVay! more, after the lapse of eight months every circumstance^
which could be taken into account, declared that health was
perfectly restored, even the health of the heart, as far as the
perfection of its living- functions constitutes its health.

In what proportion the genuine cases of acute and lymph-
depositing pericarditis, duly and seasonably treated, revert to
the conditions of this case, T have no statistics to inform me.
But standing alone the case gives an encouraging lesson. It
is this, that wo should always keep those who have suffered the
disease as long under our care and observation as possible.
Even Avhcn reparation has reached the point at which life is
safe, we should not yet abandon them. How much further it
may go wo cannot tell ; therefore we should be ready to give
to it every aid and to avert from it every hindrance. Vie are
not sure that it can go so far as to leave the heart perfectly
sound of structure. But wo arc sure that it can go to the
extent of reducing its vmsoimdness to so small an amount as to
be unfelt as a detriment to the heart's living functions.

But the reparation of the injury done by pericarditis is too
often neither thus really nor virtually perfect, but leaves un-
soundness enough to be always felt, and enough to becojne the
element of future disorganisation.

The more painfully interesting and (I fear) the larger j)art
of the subject remains. Of this some summary account must
be given, viz. of reparation beginning and proceeding but falling
short of its ultimate design, and of unsoundness diminished
indeed and brought within limits compatible with life, but felt
as a present injury and feared as the source of greater injur}'
to come.

Consider the e&cts of pericardial inflammation. They are
the undue determination of blood to the membrane itself, the
fluid efi'used within its cavity and the coagulable lymph ad-
hering to its surface. And then consider how each of them
becomes of greater amount in proportion as the inflammation is
more severe and of longer duration. Yet, if life be spared
after the inflammation has ceased, you may ahvays trust the
powers of reparation for the entire removal of the two first,
but not of the last.

19

290 CLINICAL MEDICINE. [lECT. XXIII-

The removal of the undue determinatiou of blood is the
first and the easiest stapre towards reparation. Vessels, which
naturally contain few red g-bbules, have been distended and
overloaded with them, and those, which naturally contain none
at all, and are therefore invisible, have admitted them freely.
All this results from something {sui generis perhaps) — some-
thing done or suffered by the blood-vessels and essentially
ministering to the part they have to play in the inflammation.
And it all ceases when the inflammation ceases as a natural and
necessary consequence without (as far as we know) any further
organic process whatever.

The second stage is not so easy, but yet not diflicult. It is
the removal of the effused fluid. This however must be en-
tirely removed before the heai-t can reach any condition which
is compatible with the continuance of life, even a safe condition
of permanent unsoundness.

The third and last stage towards reparation is the most
difficult of all, and doubtful whether it be ever completed. This
is the removal of the solid lymph. Removed altogether (I
suspect) it never is, and what remains of it, after reparation
has done its best, constitutes the permanent unsoundness.

But tlic solid and fluid products of inflammation within the
pericardium bear a certain relation to each other in the process
of their removal. Therefore we will take them both together in
considering how it comes to pass.

Inflammation having ceased but lymph still abiding upon
the surface and serum within the cavity of the pericardium,
the best event, now to be presumed possible, is that its opposite
folds should adhere and its cavity be entirely obliterated. And
this adhesion is unquestionably a prcjcess of reparation ; of ten-
tative reparation if you please, but still of reparation. It does
not succeed in bringing l)ack sound and healthy structure, but
it does succeed in rendering the effects of the disease less in-
tolerable, and less incompatible with the continuance of life, than
they would have been if no such adhesion had taken place.

Now adhesion between the opposite surfaces of the peri-
cardium takes place in the same manner and through the same
medium as between the opposite edges of a wound, and it is
hindered or retarded by the same impediments. Bring the
edges of a wound together and they adhere. Keep them apart.

LECT. XXIII.] UNSOITNDNHSS FROM J 'KRK CARDITIS. 291

and ilioy cannot adhere, altlioug-h the lymph bo leudy formed
to se)"vo lis the medium of their adhesion. And as soon as the
■opposite surfaces of the iicricardiuni, being- already coated with
lymph, are fairly applied to each other, they begin to adhere.
But a large quantity of serum accumulated within its cavity,
and holding its surfaces at a distance from each other would
preclude for the time the possibility of their union. And the
(quantity of serum may be large indeed.

Large however in point of fact it seldom is. It would
:alm.ost seem among the characteristics of inflammation, when it
falls upon the pericardium, that its solid should greatly exceed
the amount of its fluid products. In our clinical diagnosis of
jjericarditis, the important fact was particularly noticed, that
the exocardial murmur, the sure evidence of solid matter rub-
bing against solid matter, was heard early and continued to be
heard in almost every case without intermission, until it finally
■ ceased altogether; and the fact too that, however soon after its
final cessation the patient died, the pericardium was found
beginning to adhere. Thus the fluid within the cavity seemed
from first to last not enough absolutely to prevent the opposite
layers of lymph from coming in contact.

No sooner is this fluid, whether it be much or little, absorbed
and gone, than the solid matter is left to contract adhesion, as
it may and as it does, forthwith.

Now this process of adhesion begins with a larger or smaller
quantity of coagulable lymph according to the extent, the
intensity and duration of the previous inflammation. But
whether it be large or small, the quantity with which the
adhesion begins is probably in all cases more than is needed to
render it complete and permanent. Therefore nature seeks to
preserve just so much only as is essential to her purpose, and all
the rest which can only be a hindrance to its perfection, she
strives to remove. But this jierfeetion which nature intends is
more than nature can achieve at all times.

Any adhesion, which, occurring after acute pericarditis,
enables life to go on however insecurely, and the heart to per-
form its functions however imperfectly, is a reparation. But
the adhesion, which further guarantees the continuance of life
and enables the heart to perform its functions in a manner
approaching to the conditions of health, is a reparation in a

292 CLINICAL MEDICINE. [lECT. XXIIT.

lilfflier sense. And to do this it must be of a certain kind and'
degree.

Be it however remembered, that all adhesion of the peri-
cardiimi, whatever be its kind and degree, although in references-
to the preceding inflammation it partakes of the nature of repa-
ration, yet in comparison with original structure, and with
reference to consequences, partakes of the nature of rmsound-
ness. Only its character of reparation is more apparent in one
case and its character of unsoundness in another. The former
has been illustrated by some conspicuous instances. It is the-
latter with which we have now chiefly to do.

The most common appearances of disease are often the fullest
of instruction, and to such I am now going to refer. When
there has been only one known attack of pericarditis, occurring-
long enough ago to allow as complete a reparation of the injury
left behind as might be possible in each case, then the customarj--
appearances on dissection are some of the following : —

1. There may be an universal adhesion of the pericardium
and a complete obliteration of its cavity effected by the least, or
by hardly any, apparent medium of adventitious substance.
Ilere we have an example of reparation nearly complete but not
of absolute reparation ; of the least degree of permanent un-
soundness but still of unsoundness. It has been shown, that
these conditions may subsist without further harm to the func-
tions and structure of the heart. But then it was where there
had been no known previous attack of acute inflammation.
Hence however, it was thought fair to conjecture that where
there had been a previous inflammation and life had afterwards
"•one on without the least evidence of further harm to the func-
tions and structure of the heart, these same were the conditions
which might have obtained. I say, " it was thought fair to
conjecture" and that is all. For, although I have known a
few who after simple acute pericarditis have recovered and
lived apparently in perfect health, yet I have never had the
opportunity of examining after death the state of the heart in
any such instances. I have indeed often met with " this almost
complete reparation and this least degree of unsoundness" ap-
pertaining to the pericardium after death, where inflammation
had been formerly suffered. But it has been accompanied with
unsoundness of the endocardium also, and further disorganisa-

LECT. XXIII. J TJX.SOUNDNKSS FROM rKIMCAUl >ITIS, 293

tiou ill the shape of u thickened muscular structure, uud of a
dilated ventricle has been .superadded, and all have been notified
by syiuptouLs during life. It is a question Nvith me then after
nil, what are the consequences which naturally result to the
functions and structure of the heart from simple adhesion of
the pericardium. For I have not facts enough to appeal to of
the sort which are required to settle it. Pericarditis indeed is
common enough ; but not simple pericarditis. The original
disease is oftener a complex of pericarditis and endocarditis
than pericarditis alone ; and the original unsoundness a complex
of the partially repaired effects of both. Hence whatever de-
triment the heart is afterwards found to suffer in its functions
.and organisation, it is difficult to make sure either how much is
due to each, or whether the whole may not be imputed to one ;
how much the thickened valve produced, and how much the
adhesion of the pericardium ; or whether the thickened valve
may not have been exclusively the source of all the mischief,
and the adhesion of the pericardium altogether blameless from
iirst to last.

2. But, instead of the adhesion of the pericardium being-
universal, and the obliteration of its cavity complete, both may
be partial only ; partial, however in different ways. There may
be a single adhesion over a considerable space, limiting the one
•cavity by so much. Or there may be many adhesions parti-
tioning the one into many cavities. These partial adhesions
are often very firm and close, and in their intersj^aces the
surfaces of the pericardium are found lying in contact and
ununited and apparently healthy.

Now measuring and comparing things as the}' merely strike
the eye, we see in these conditions a less amount of unsoundness,
.than in a pericardium altogether adherent and having its cavity
altogether obliterated. J Jut looking to consequences we must
judge otherwise. These loose interspaces are prone to enter-
tain inflammation afresh. After death from secondary peri-
carditis the heart has been found apparently surrounded with
many little separate abscesses, which have turned out to be
.collections of purulent matter between the folds of the peri-
.cardium, where it had here and there failed to contract adhesion
.after a former inflammation.

In tke radical cure of hydrocele, more is needed, that we

294 CLINICAL MEDICINE. '(_LECT. XXIIF.

may make sure of it, than to draw off tlic fluid. Let it be drawn
off twenty times, tliere is still a fear that it will in all proba-
bility return, as long as there remains a serous cavity for it to-
return to. The cavity itself must bo obliterated, and surgery
designs and interferes that it shall be so. It aims to produce-
throughout the entire sac just so much inflammation as shall
cause to be deposited, not here and there mercl}', but on every
part of its ojiposite surfaces Ijanph enough, but not more than
enough, to procure their adhesion. The absolute obliteration oi
the cavity of the tunica vaginalis by adhesion with the least
possible quantity of adventitious matter, constitutes the radical
cure of hydrocele. Here what is surgically the radical cure iu
reference to one organ is the same, which medically in reference
to another I have called " almost complete reparation and the
least degree of unsoimdness." Whatever be the security
against recurring disease in the one case must be the security in
the other.

3. But it is not only the extent of the adhesion that is various^,
but the quantit}' of the uniting medium also. Between a slender
tissue that holds, almost invisibly, the opposite surf aces together,,
and a solid substance half an inch in thickness, there is found
every intermediate degree. And these extremes and several
intermediate degrees arc apt to be found in the same heart, dis-
playing larger and smaller measures of unsoundness at different
points, and a vast aggregate of unsoundness upon tlic whole.
Now this state of things may be met with at remote jieriods
after some known attack of pericarditis, from which there has
been no return to health, but ever afterwards a sensible hurt and
hindrance to the living functions of the heart and a jniserable
existence. The unsoundness is both permanently great and un-
alterable for the better. Reparation has been able just to save
life, and allow it to go on and nothing more. I say vmalterable
for the better, but not unalterable for the worse. For here are
just those conditions which involve the })cril of secondary in-
flammation.

Such, generally, are the forms and degrees of imi)erfect re-
paration found after a single attack of pericarditis. They are
in fact forms and degrees of permanent unsoundness. They are
calculated to interfei-e some more and some less with the natural
functions of \\\v heart, some to bear heavily and some lightly

LECT. XXIII.] UNSOUNDNK.SS FROM PERICARDITIS. 295

upon a man's future woll-being, some greatly to abridge the span
of life, and some still to allow its long- continuance.

But there is a cuDiiilative unsoundness resulting from more
than one attack of pericarditis. To the imperfectly repaired
detriment done by a first inflammation may be added the detri-
ment done by a second. And this too may be imperfectly
repaired ; and thus, after several infiammations, each adding
something to the permanent injury whicli it found, if life
continue, the cumulative unsomidness may ultimately become
enormous.

Of this cumulative unsoundness something has already been
said incidentally in a former lecture, when I gave certain cases
and dissections to illustrate the clinical history and diagnosis of
secondary inflammations of the heart, and in the present lecture
when, describing the forms of unsoundness left by a first peri-
carditis, I pointed out those which rendered the heart more apt
to entertain a second. Hence it must appear, that there are
cases in which after death the effects of a second or any after-
attack of j)ericarditis are plainly distinguishable in the same
heart from those of a first or of prior ones, the cases namelj'
where from such second or after-attack the patient has recently
died. But these show the beginnings only of that cumulative
unsoundness, of which something yet remains to be said. I will
content myself with first describing it sim])!}' as it appears
when it has run on to some of its highest degrees, and after-
wards add a brief commentary.

The adventitious substance intermediate between the adhering
folds of the pericardium has been found more than an inch in
thickness, its texture sometimes laminated like the coagulum of
an aneurismal sac, red or tawny near the heart, and pale or
white more remote from it, sometimes of a mixed consistence,
in part almost liquid and purulent and in part solid or tubercu-
lous. Or the adventitious substance has been of one uniform
texture, either so like muscle as to be at first mistaken for the
fleshy substance of the heart itself, or so far firmer than muscle
as to resemble flesh hardened in brine, either much paler than
the heart, or much redder from being deeply injected with
blood. This tough flesh-like substance may occup}^ a portion
only of the surface of the heart or the whole of it. I have seen it
opposite the right auricle, while every where else the pericardium

296 CLINICAL MEDICINE. [lECT. XXIII.

has closely adhered with little intervening medium, and I have
seen it enveloping the entire organ and forming roimd it (as it
were) another case of muscle. And then, if (what often happens)
the muscular substance of the heart itself he augmented, a strange
spectacle is disclosed on dissection. There is an enormous mass
displacing the lungs and leaving nothing visible in the entire
front of the chest but itself.

These results are very striking. But can wo interpret them
truly? Can we take them and read them (as it were) back-
wards, and so tell the course and clinical history of the inflam-
mation or inflammations which produced them ?

In all cases, from what we know or from what we learn of
the patient's previous life, this one point is clear beyond a
doubt, namely that the vast amount of unsoundness had its start
or point of departure from an attack of pericarditis several years
ago. And in many cases from what we know or what we learn,
thus much more becomes certain or highly probable, namely
that the original unsoundness received accessions from distinct
subsequent attacks of inflammation. We seem to read thus
much in the character of the morbid deposits, when there are
layers of lymph upon lymph varying in colour and consistence,
or when matter soft and friable intervenes between firm and
tough adhesions.

But in other cases, neither from what we know nor from
what we learn of the history of the patient's life or the nature
of what is found after death, can v/e get all the sure insight we
desire into those morbid processes, which succeeding to the
original pericarditis have built up the vast mass of unsoundness
eventually disclosed. The original pericarditis, we are told, left
beliind it precordial anguish and palj)itation, and these never
afterwards ceased but became greater and greater to the last.
But in the mean time it is uncertain whether there were any
fresh attacks of inflammation or not.

In such cases we are left to choose between two reasonable
conjectures. Fresh and distinct attacks of inflammation might
have arisen and brouo^ht their contingent to the oriffinal un-

o bo

sovmdness and yet all sure notices of them have lain concealed
under the magnitude of the abiding distress. How possible
this is, has been already shown when we were considering the
diagnosis of secondary pericarditis. Or, without any fresh or

LECT. XXIII.J UNSOUNDNESS FROM I'KKICAK'DITIS. 207

distinct attacks, the advcntitiuus texture first formed might
still continue to entertain tlie inflammation which formed it,
and so carry within itself the principle of its own increase.
This, being- ever afterwards slowly hut ceaselessly at work, goes
on to amass by interstitial deposits a greater and greater cumu-
lative unsoundness. The uniform colour and consistence of
the adventitious substance seem to countenance this last con-
jecture.

298 CLINICAL MEDICINE. [lECT. XXiy.

LECTUKE XXiy.

PERMANENT r]SSOrND>"ESS OF TlIK EXDOCAKDIIM AND PERICAR-
DIlJM Fl{0:\r DISEASES OF A SPECIFIC AND MALIGNANT

NATURE, ESI'ECIALLY FRO^[ ANALOGOUS FORMATIONS. THEIR

ANATOMICAL ( IIARACTEK. THEIR CLINICAL HISTORY. — THEIR

CLINICAL DIAGNOSIS. OIR KNOWLEDGE OF THEM COMPARED

AND CONTRASTED WITH OVJi KNOWLEDGE OF INFLAMMATION.

Thus far vre have been considering tlie permanent unsoundness-
derived to the heart from disease, and that disease inflammation,
and that inflammation of the jiericardium and the endocardium ;
in other words the local eflects of one or of several attacks of
inflammation upon these structures when they are left imper-
fectly repaired. But permanent unsoundness may be derived
to the heart from disease, and that disease be of the endocardiimi
or the pericardium and yet not have the nature of inflammation.
The several textures which compose the heart are not exempt
from those diseases which, by whatever name they are called,
I'esidt in formations different from the natural structures of the
body, such as tubercle, carcinoma, cephaloma, &c. But these
diseases have not any special pathology resjjective to their seat
within the heart, or (what is more to our jDurpose,) any distinctive
history, diagnosis or treatment. Therefore it would be going
out of our way to enlarge our notice of them. I would only
observe of that disease with Avhich experience has made us most
familiar, that it seldom afl'ects the heart. I have in a few rare
instances seen the pericardium studded with scrofulous tubercles,
when they have been coincident with tubercles of the same
character in other parts of the bodj^ and especially in the lungs.
Scrofulous disease seems to have a natural preference for one
organ or structure before another. Its tubercular dej^osits are
apt first to take place in a single part and then, if life continue,
to involve other parts almost in a certain order. And life not
unfrequently docs continue long enough to allow them to spread

Li:cr.xxivjsiM:(:iFi(;r)Er()siTSiNKNi)O-Axi)rKRir:ARi)iiiM.290

beyond the pint first and chiefly and fatally affected, and to
reach two or throe others. Yet tliey seldom reach the heart.

But the heart is apt to derive permanent unsoundness from
diseases (if they deserve the name) different from all these, and
different too from inflammation. They consist of (Avhat are
called) deposits of analogous tissues : analogous, that is, tO'
healthy tissues, as partaking of their nature, but now having
the character of disease, since they now occup}' the situations
\\here in health they arc never found. Thus cartilaginous and
osseous matter is found in the pericardium and the endocardium.
It is not indeed either perfect cartilage or perfect bone, but it
approaches to the one or the other both anatomically and
chemically.

Now the strict local pathology of these analogous tissues,
the manner of their origin and growth and increase within the
heart I must leave you to learn from other instructors. Our
proper business is with their lirina history and their diagnosis,
and their treatment. But some idea of their objective reality
sliould be brought and kept before the mind, if we are to take
any just measure of their living events and form any just
expectations of the effects of remedies upon them. A few par-
ticrdars therefore coucerning them require to be briefly stated.
The endocardium is much more frequently the seat of these
analogous formations than the pericardium. But a specimen
of ossified pericardium is to be found in most museums.

In the specimens I have met with, the manner in Avhich the
bone has been deposited has been very peculiar : it has consti-
tuted one large plate or ring, running round the heart ; or even
a sort of case, which has nearly enveloped the whole organ.
From this ring, or case of bone, processes sometimes are given
ofi", which penetrate the substance of the heart, and reacli even
to its cavities.

Lai-nncc met with an instance in which this sort of bony case
A\-as formed around the heart, and gave off processes, which
penetrated its cavities in the manner described: and he satis-
lied himself by dissection that the morbid growth was developed
between the fibrous and serous layers of the pericardium, since
he was able to separate it, and still leave the heart covered by
the serous fold of its investing membrane.

In the endocardium analogous formations are more yarious-

■-300 CLINICAL MEDICINE. [lECT. XXIV.

- and more frequent. Cartilaginous depositions are often found
beneath the membrane where it is single ; or between its folds
where it is double, in the situation of the valves ; and thus they
seem rather to belong to some structure contiguous to the
membrane than to the membrane itself. Such depositions will
proceed to a considerable extent, while the membrane still
remains free from disease. From a valve, which has been thick,
opaque, and cartilaginous, I have seen the membrane separated
• on both sides, and transparent ; the opaque and cartilaginous
matter being left behind. Where, in cartilaginous depositions,
the lining of the heart has become puckered and uneven on its
surface, and the valves shortened and altered in their shape,
the membrane itself participates in the disease, and is generally
incapable of being separated from the subjacent structure. But
, great thickening may take place in the situation of the valves,
from deposition of cartilage, without any unevenness of their
surface or alteration of their shape ; and imder these circvmi-
stances the membrane itself you may expect to find hitherto
.exempt from disease.

Osseous depositions are always, I believe, originally formed
beneath, or exterior to, the membrane, both in the heart and in
the arteries. There are two circumstances especially worthy of
remark in this process of ossification : sometimes it is a pure
. and unmixed process : bone is formed and nothing else. It is
deposited in minute granules, or little brittle scales, or in plates
of a larger size ; and the intermediate spaces, whether in the
heart or arteries, preserve their natural and healthy appearance.
At first, these granides or scales, or plates of pure bone, are
covered by a delicate pellicle, Avhich is in fact the internal
membrane of the heart or artery, separating them from the
immediate contact of the circulating blood. But in process of
time, as they increase in size, and become rough and unequal
on their surface, they cause a rupture of the internal membrane,
and have now nothing to separate them from the immediate
contact of the blood.

Sometimes ossification is a mixed i^rocess, or rather, the
result of another morbid process preceding it. With the car-
tilaginous depositions already described there is an admixture
of bone. The quantity of bone generally bears a small propor-
•i.ion to the cartilage when they both occur together, as if the

LECT.XXIV] SPECIFIC DEPOSITS IN KNDD-ANDl'KRICAK'DIHM. 301

bone proceeded from the cartiluf^e, and not the cartilage i'roiu
the bone. It is sometimes seen growing from the surface of thi.^
cartilage, and is sometimes deposited in its substance, and only
detected by the knife.

Enough has been said of these analogous formations to sho\\-
that they constitute a real unsoundness of the heart. But
irhcnee come they, and ichi/ come they in the living man ? Have
tliey any clinical historj^ Avhich can tell us ? Assuredly tliey
hare a clinical histor}^, but it is no such histor}^ as tliat which
belongs to an acute endocarditis or pericarditis. They have no
sudden fever, no abrupt pain or swelling of external parts, in
the midst of which they declare themselves for the first time,
and which fix the exact date of their origin and give intelligible -
intimations of their very nature. Yet still they have a clinical
history, but it is such as belongs to all clironic disease.

When disease is essentially acute, the preceding circum-
stances conducive to it are (so to speak) acute also. They are •
often as marked and as palpable as the disease itself, and we
seldom need to look far back before wo find them. Tlie
pneumonia of to-day comes from exposure to cold which was
bitterly felt yesterday. The fever of to-day comes from expo-
sure to some known contagion or some malarious influence in
the course of last week. The endocarditis and pericarditis of
to-day are only what we have been expecting and fearing since
our patient has been ill of acute rheumatism.

But when disease is essentially chronic, the preceding
circumstances conducive to it are (so to speak) chronic also.
They are often covert and far-fetched and hard to imravel, and
we must often look back to a man's whole life, or to tlie life of
his progenitors, before we find them.

Thus in a multitude of cases (for when the question is of
chronic disease a single case proves nothing) where the lining
membrane of the heart and arteries has been beset with cartila-
ginous or atheromatous or earthy deposits, the patients have
been habitual spirit drinkers for j^ears, and the most con-
spicuous conditions antecedently presented by them have been
the failure of many functions and the growth of structural
disease in many organs, especially in those subservient ta
nutrition.

Again, in a multitude of cases the patients have not beea

302 CLINICAL Z^IEDICINE. [lECT. XXIV.

grossly intemperate but habitually luxurious, and the ailments
•chiefl}^ suffered by them beforehand have been gout and its
■concomitants.

Again in a multitude of cases the patients have always lived
in the way most likely to ensure health, and health they have
always enjoyed until old age has arrived ; and then have
appeared the authentic signs of valvular disease of the heart.

But, when all these circmnstances have been noted and
allowed, they only make one feel more strongly the need wc
have of knowing something more. The history of diseases, as
distinct from their diagnosis, is valuable in proportion as it
shows what are their natural preparatives, and what are tridy
their exciting and predisposing causes.

Intemperate habits, and gout and the gouty constitution
and its appurtenances, and old age, all deserve our notice as
belonging to the history of the heart's unsoundness produced
by chronic valvidar disease. But intemperate habits, and gout,
and old age must include within them something more general,
something common to them all, something working more
■expressly to its end, and determining the formation of cartila-
ginous and osseous growths within the heart and arteries by a
more direct pathological necessity. But what it is we know
not.

We talk sometimes of diseases v.'hich come of themselves,
meaning that they come without any sure forewarning that
they are coming. And yet it is probable that such diseases,
which are mostly chronic, are more strictly annexed to inx'-
ceding conditions, although it cannot be shown what those
conditions are, than are acute diseases. A man may have acute
rheumatism and yet escape inflammation of the endocardium or
the pericardium. He may be exposed to malaria or to contagion,
and have no fever. He may encounter a blow, or a fall, and
suffer no hurt. Here the conditions which precede are plain
enough, and so are the diseases which follow, when they really
do follow. But the fact that they do not always follow takes
them out of the category of inevitable consequences. And
further, when they do follow, whether they be fevers or inflam-
mations, thej'- are cured, if they be curable, irrespective of the
conditions out of which they arose. Being once produced they
are set free from subjection to the causes which produced them,

'LECT.XXrv] SI'KCIFIC DEPOSITS IN HNDO- AND I'KRICARDIUM. 303

and thenceforth yield obedience to influences cither inherent in
themselves!, orbvong-ht to bear upon tliein from without, nence
they sometimes cease spontaneously, and sometimes on the
-application of rcuuvlies ; such r(nncdi(^s as operate plainly in
■counteraction of present morbid conditions, as, for instance,
anodynes for present pain, salines for present fever, bleeding
lor present hardness of the pulse. But with chronic diseases it
is often far otherwise. While all that has preceded them has
been so little rcnuirkable as to lead us to believe that they came
of themselves, yet when once they have declared their existence,
then everything- has seemed to show that they had their origin
;ind still ha^'c their continuance from a root much deeper than
themselves. And if such diseases be curable, they are not
cured by remedies counteractive of present morbid conditions,
<^ither by anodynes for present pain, or by salines for present
fevc]', or by bleeding- for present hardness of the pulse. There
7nay be pain enough, or fever enough, or hardness of pulse
enoug-h, and these may requii'c their appropriate remedies,
^modynes and salines and bleedings, and they may yield to
them. But while they yield, the diseases remain, because they
are indissolnbly annexed not to those conditions which we see,
but to other conditions which do not appear.

Well ! then by what remedies rn-c essentially chronic diseases
cured, when they are indeed curable? By remedies whose
effects from day to day and from week to week are inappre-
ciable, and are seen only after the lapse of years. And what
are those effects which are thus tardily and g-radually brought
to pass ? Indeed they can only be expressed in very general
terms ; terms sufiiciently denoting their reality and the imper-
fection of our knowledge concerning them. Those effects are
the change of' constitutional weakness into strength ; the change
of the solids and fluids of the body from pravity to healthfulness,
and in the meantime the disappearance of the disease.

It appears then that these analogons formations in the lining-
membrane of iho heart, which occasion its permanent unsound-
ness, have no such clinical history as can furnish us with any
certain knowledge whence or why they come, or with any svire
indications of treatment by which they can be prevented or
■cured.

But being once formed, have they not a clinical diagnosis ?

304 CLINICAL MEDICINE. ["lECT. XXIV^

Indeed they have ; a diagnosis, Avhicli, in one point of view,,
reveals more than could have been conceived possible of
any internal disease, but which in another reveals nothing-
at all. By present living symptoms we can ascertain their scat
satisfactorily enough, but we cannot pierce through it into their
Tiafnre. And herein they share the common condition of almost
all internal chronic diseases, in which the easy and often sure-
diagnosis of thci)- scat is strikingly contrasted with the dark
and conjectural diagnosis of their nature.

I^ow this condition, if it be indeed as general as I represent
it, is surely worth enquiring about. Besides it is a condition
which bars the rational treatment of all the diseases that it.
embraces. And if this largo class of diseases of the hearty
which has long been familiar to our knowledge anatomicall//,.
still remain far beyond our reach rcmediaUy, we are fortunate,,
for our own credit's sake, in being able to show that the-
obstacles in the way of our art are really insurmountable.

Of the signs by which physicians become acquainted with
diseases in the living body, some are expressive of their nature^
and some are expressive only of the parts they occupy. The-
first flow directly from their essence, and may be called essential
symptoms : the second are derived from the disturbed function.^.-
and sensations of particular organs, and may be called acci-
dental. Tliis distinction between essential and accidental
symptoms is one of great practical importance.

Some diseases have both orders of symptoms most strongly
marked. An acute inflammation has its essential symptomSy,
which are commonly the same, in whatever j^art of the body it
is found, such as general heat and general excitement of the
vascular system. And these teach us that it really is an acute
inflammation, and how to treat it. Moreover, it has its acci-
dental symptoms, which are different according to the part it
occupies, whether the heart, the limgs, or the brain, such as.
palpitation in one case, impeded respiration in another, and
disturbance of the senses and the intellect in a third. But
these alone teach us nothing concerning the inflammation, and
give us no guidance or direction in the treatment of it.

Again, some diseases have no essential symptoms whatever
but those only which are accidental, and which appertain
entirely to the organs they occupy. A fungous excrescence, or

LECT. XX 1 v] SPEC 'I VK' IJEI'OSIT.S I N EN DO- AND PElilCA ItDIUM . 305

a serofuloxis tubercle, being situated in the brain, may be
accompanied by a pain in the head, an hebetude of the senses
and intellect, and an impaired exercise of the voluntary
muscles ; but the same symptoms have arisen from tumours of
other kinds, and even from the lodgement of a foreign body,
such as a musket ball, in the same situation. They have
nothing to do witli the essence of the tumour in question, and
profit us notliing in suggesting any method of cure. They
have, in fact, no rational treatment ; and simply for this reason ,
because they have no essential symptoms.

The symptoms which flow from the essence of the disease
are present with its very beginning, and accompany the whole
process of its formation; whereas the symptoms which are
accidental to it do not always appear until it is already formed,
and often not until it has endured for a considerable period,
and reached a considerable magnitude. Further, it may be
stated generally, that essential symptoms belong more especially
to acute diseases, and that diseases, in proportion as they are
more chronic and of (what is called) a specific character, are
apt to lie concealed under symptoms which are derived less from
their own nature than from the parts they occupy.

With respect, then, to diseases of the heart, as far as they
are declared by essential symptoms, we have an early intima-
tion of their existence, a knowledge of their real nature, and a
guidance in the administration of remedies for their cure ; but
as far as they are suggested by accidental sj^mptoms only, our
knowledge is not of their nature but of their efiects, and our
treatment is not directed to their cure, but to the palliation of
inconveniences which are consequent ujjon them.

Between endocarditis and pericarditis, and the cartilaginous,
atheromatous, and osseous transformations of its lining mem-
brane there is this wide distinction, that the former are of an
acute, the latter of a chronic character ; and this real difference
in their nature determines the difference in the degree of
knowledge we have concerning them. As morbid anatomists,
we can see and describe the visible characters of both with equal
precision ; but as physicians, seeking to mark the period of
their origin, and to measure the rate of their j^i'ogrcss, as the
indispensable conditions of adapting a remedy to their cure, —
■as physicians, we know much that is certain and useful con-

20

306 CLIlSriCAL IMEDICINE. [lECT. XXIV,.

ceming one class of diseases and very little concerning the
other.

Endocarditis and pericarditis, by virtue of symptoms wliicli
are essential, and derived from their own nature, of symptoms
which are jjresent with their beginning, and accompany the act
of their formation, submit themselves to medical treatment
with tolerable success. They often bring the knowledge of
their existence within the period which includes the possibilitv
of their cure.

But these analogous formations of the lining membrane hav-
ing not essential but only accidental symptoms, merely discover
tchere theij are, not tchat they are, or how they are to be treated.
The time of their accession, and the early stages of their pro-
gress, are alike unknown ; and the notice of their existence is
only at length supplied when new changes of structure have
arisen in the heart itself, and new disorders in the constitution
at large, and both the original and all the consequent maladies-
are absolutely incurable.

Disorganisations of the heart, how complex soever and
extensive they may be, have often their origin in the unsound-
ness which remains after endocardial or pericardial inflamma-
tion, or in that which results from these analogous formations.
If in the former their history is capable of being traced from
their commencement, and pursued throughout their course
regularly and connectedly ; if in the latter, their history must
be taken up at a period remote from their origin, and will
always be most doubtfully and imperfectly made out.

LECr.XXV.l DISIIASES OF HEA.RT's MUSCIJLA.R STRUCTURE. 301

LECTURE XXV.

DISEASES OF THE HEART's MUSCULAR STRUCTURE. ACUTE INFLAM-
MATION TERMINATING IX THE FORMATION OF TUS. CzVSES.

EXPLANATION OF THE NATURAL DIFFICULTIES IN THE WAY

OF ITS DIAGNOSIS.

I MAY seem perhaps to have passed by all consideration of tlie
muscular structure of the heart, as if it were altogether incap-
able of disease. But I have only postponed it, thinking that
its diseases might be advantageously regarded in contrast or
comparison with those of other structures which have already
been the objects of our inquiry. For indeed the muscular
structure of the heart has its diseases ; yet many of them are
during life broiight within our knowledge only in very small
measures and degrees, and some of them not at all.

But it is a great thing, let me tell you, to understand the
imperfections of our knowledge, and so to analyse its defects,
as to be made aware what parts of a subject still remain (as it
were) in the shade, and need to be brought into clearer view by
the light which future observation may bestow upon them.
Therefore, in reckoning what information we have concerning
diseases of the muscular structure of the heart, I shall be careful
to point out what wo have not. By its diseases, I mean processes
essentially morbid, which bring change and detriment to its
elementary texture, not mere alterations of size and shape and
capacit)'', leaA'ing the elementary texture otherwise unchanged
and uninjured; a distinction most needful here to be borne
in mind.

The muscular structure of the heart is capable of acute,
pervasive, pus- depositing inflammation. But this inflammation
has no customary assemblage of preceding or concomitant cir-
cumstances, i.e. no clinical history to tell us when to expect it,
no sure diagnosis to tell us when it is present, and conse-

308 CLINICAL MEDICINE. [lECT. XXV.

quently no definite indications of treatment either for prevention
or cure.

A boy, twelve years of age, was in perfect health on Satur-
day night and dead on the following Tuesday afternoon at two
o'clock. He had in the opinion of all who saw him the severest
inflammation of the brain. The attack was sudden with great
heat and frequency of pulse. He had delirium and convulsions
and pointed to his forehead as the seat of his pain. At length
he sank into a state of insensibility and died. Upon dissection
not a vestige of disease was found within the cranium, but the
heart was the seat of the most intense inflammation pervading
both the pericardium and the muscular substance. Four or five
ounces of turbid serum with flakes of coagulable lymph floating
in it were found in the cavity of the pericardium, which had
its internal surface covered in various situations with a thin
layer of reticulated lymph. Thus far there were the evi-
dences of acute inflammation of the pericardium at an early
stage. There was no adhesion of the opposite surfaces ; the
lymph and the serum had been eff'used together, and the serum
had partially washed away the lymph as it was deposited.
Further, when Ihe heart itself was divided, the muscular fibres
were dark- coloured almost to blackness, loaded with blood, soft
and loose of texture, easily separated and easily torn by the
fingers ; and at the cut edges of both ventricles small quantities
of dark-coloured pus were seen among the muscular fibres.
The internal lining was of a deep red colour without any
efl'usion of lymph.

Here the acute inflammation of the muscular structure was
evinced in a manner which had never been seen before. The
softening and friability of its texture would perhaps have been
enough to bespeak it inflamed, but here was an actual deposition
of pus.* This was a singular specimen of disease. It happened
thirty years ago. But I have never seen another like it ; and
I only know of one other like it, which occurred twenty years
afterwards to Mr. Salter of Poole. I will endeavour to abridge
the case, taking as much care as I can to preserve its points of
interest and instruction.

* This case was reported by Mr. Stanley thirty years ago. I was witness
of it at the time, and present at the examination after death. — Med. Chir.
Trans., \o\.. vii. p. 323.

LECT.XXV.] DISEASES OF HEARt's MUSCULAR STRUCTURE. 309

A man 50 years of age, by trade a glover, but formerly a
dragoon, applied to Mr. Salter for advice and gave this account
of himself. Six weeks previously, while walking, he was seized
with pain at the lower part of the chest inclining towards the
left side. It was of short duration but of extreme severity,
producing faintness and cold perspiration. A week afterwards,
returning from a walk of three miles, he was seized Avitli the
same sort of pain with the like fearful accompaniments. And
now the attacks became more frequent but varied in their
degree of severity and in the occasions producing them. They
sometimes arose independent of exertion or seemed to arise from
the mere act of raising the arm. At length a considerable
uneasiness of the left arm often attended the pain in the chest.
Auscultation could find nothing wrong either in the heart or in
the lungs. The symjatoms obtained some degree of relief from
certain remedies addressed to the stomach and bowels, which
their present disordered state seemed to call for.

Six days after Mr. Salter first saw him, and seven weeks
after his first attack, he was seized with his longest and severest,
his last and fatal paroxysm. It continued sixty-five hours and
never ceased until it killed him. Its accession was with the
consciousness of coming death. His face became all at once
pale and his features sharp and his expression anxious and his
breathing oppressed. He could not lie down. He j)laced his
hand over his sternum and said " it all lies here." The pain
was now a dull heavy pain. Still the heart's action was natural,
air passed freely through both lungs and the pulse beat regu-
larly 80 in a minute. He was bled to 10 ounces and blistered.
This was early in the niorning.

In the evening his sufferings and anguish were the same in
kind but vastly augmented. They were too great for him to
express what he felt ; too great to allow any satisfactory exa-
mination to be made of his chest. The pulse had lost in power
and gained in frequency. It had reached 120. He was now
ordered four grains of calomel and one grain of opium every
four hours. The night was passed in indescribable distress. The
next morning he was still alive ; yet the beats of his pulse were
scarcely to be felt or the sounds of his heart to be heard. The
surface was losing its heat and positive pain Avas less. He con-
tinued however to live through that day and through the fol-

310 CLINICAL MEDICINE. [lECT. XXV.

lowing night and through the next day until eleven at night,
with all his extremities cold and his pulse imperceptible, and
then died, his mind remaining clear to the last.

Now in this case it was pretty evident that the heart was
the seat of disease. Eut no experience \\'hich I possess could
have enabled me to say, during the life-time of the patient,
what that disease was. These were the apjjcarances upon dis-
section. In the pericardium both where it was loose and where
it covered the heart, especially opposite the left ventricle, there
was excessive vascularity; and where it was attached to the
diaphragm the excessive vascularity was mixed with ecchy-
mosed spots and blotches. But there was neither serum nor
lymph nor pus effused from any part of the membrane. Within
aU. the cavities of the heart coagula were largely accumulated.
But there was no vestige of disease at any part of the internal
lining. The great centre of disease was the muscular substance
uf the left ventricle.

" Excepting a small portion of a few lines in thickness on
either surface, the left ventricle had entirely lost its muscular
colour ; it was of a lightish yellow hue but still preserving the
librous character of muscle. From all the cut surfaces of the
vaiious sections, which were made, could be scraped purulent
matter. In some parts absorption had taken place leaving
small cavities in the muscular substance, varying from the size
of a pin's head to that of a small pea. These were all filled
with pus."

What was further found, viz. half a pint of serum in the
right pleural cavity and the complete engorgement of the left
lung with serO'Sanguineous fluid, might be looked upon as the
result of the last day's agony.

Upon a review of the whole case Mr. Salter comes to the
following conclusion. It appears sound and just and embraces
(I believe) the real truth of the matter. It is this ; " that a
chronic inflammation of the muscular substance of the left ven-
tricle of the heart constituted the primary disease and that it
no doubt existed at the time the first symptoms occurred : [this
supposition, if correct, explains the effect of bodily exertion,
even of the most trifling kind, occasioning so much distress:]
and that the accession of the violent sj'mptoms may have arisen

I.ECT.XXV.] DISEASES OF heart's MUSCULAll STKUCTUKE. 311

from the inflammation then assuming an acute form and
extending- to the pericardium/'^

What a lesson do these two cases contain! Watched b\'
oompetent observers from first to last and from hour to hour
with curious and earnest interest they baffled all reasonable
calculation of what was going on during the life of the patients.
j:\jid yet after death dissection disclosed the commonest and the
best understood (so we think) of all diseases, inflammation 4
inflammation, which had begun and proceeded in its most
ordinary manner, and which had ended in its most ordinary
•event, suppuration. But it was inflammation of the muscular
fiubstaiicc' of the hcarl.

So it was not the natui'e of the disease that lay at the root
of the mystery, but the part it occupied. For be the nature of
ii disease ever so well known, prior to experience who can tell
how any living organ will be affected by it ? But there was
not tlien, and (as far as I know) there is not now, beyond what
these two eases have taught, any experience in the world, ho^^'
the living heart is afl'ected by acute suppurative inflammatioii
•of its muscular substance.

And what now have these two cases really taught us':"
Have they left (what may serve for) a traditionary experience
to future observers enabling them to discern and to treat acute
inflammation of the heart's muscular substance in the living
man r* Surely they have not. They have taught the possibility
of su^h a disease in such a part, and nothing more.

Yet do these same cases contain a lesson of a more general
.and comprehensive kind. And we should do well to consider
it. In showing us our defective knowledge of the disease in
question, they allow us to catch a glimpse of a great patho-
logical secret. They give us some intelligible notion why the
most acute diseases often are, and needs must be, imperfectly
■developed in their living signs.

The general vascular system and the general nervous system
serve each as a glass in which we are fain to read the reflection
•of diseases, when we have no direct vision of the diseases them-

* Med. Chir. Trans., vol. xxii. p. 72. Mr. Salter .^ valuable paper slipuld
be carefally stinlied. I Lope it has not .siilfcred injury at my bauds in the
.attempt to condense it.

312 CLINICAL MEDICINK. 1 LECT. XXV,

selves. Here, as in higher philosophies, we take measure of

things by their shadows.

• • • 1

Diseases -which are local in their seat and origin are said to

have their constitutional symptoms. By this nothing more is

meant than that they affect the general vascular system or the

general nervous system in certain ways. Aii'ecting the vascular

system they produce the phenomena of fever, cold and heat and

perspiration, either of them alone or mixed, or interchangeably

with one another, also strange movements and impulses of the

heart and arteries, and strange acceleratings and retardings of

the blood itself. Affecting the nervous system they produce

new and strange sensations of infinite kinds and degrees,

pain and anguish, excitement and depression, and, when they

reach the nervous centres, as they often do, delirium and

convulsions.

From these several modes of action and suffering in the
vascular system and in the nervous system we gather that por-
tion of our knowledge of diseases which is most eminently
practical. For, however suie an insight we may have into the
essential processes which constitute diseases within any part, we
cannot stir a step safely or profitably in their treatment, mitil
we learn how the vascular system or how the nervous system is
affected by them, provided the}'^ be of a nature to affect these
systems at all. Where are the signs to be sought of acute in-
flammation when it occupies an organ out of sight ? Where
the signs by which we arc to make sure of its existence, to
measure its force and the rate of its progress, and to apply the
remedy ? Mainl}'- in the general vascular system and siib-
ordinately in the nervous.

Well ! but do all diseases of the same nature, which arc
capable of affecting the constitution, display themselves in their
constitutional symptoms at all times after the same manner and
to the same perfection ? Does inflammation do so ? I think
not. And herein lies one secret at least of the defectiveness of
our knowdedge.

Call them sympathies or what you will, by which all the-
blood-^■cssels and all the nerves of the body share the actions
and suficrings of a part diseased, they must have invariable
relations and a constant order, if the phenomena which they
display are to be constantly relied upon. Bui the mere mag-

LECT, XXV.] DISKASKS OF HIOAirr's MIJ.SCIILAU STIflJCTlJJM:. '513^

nitude of the cliseust^, or the piirt it occupies, or the tcmperu-
luent of the patient is ever interfering- a little with these con-
stitutional syinpathies, and is ever disturbing- a little their
natural relations and order ; not more however than we ean-
easily make allowance for. And if tliis were all it would bo
well. I3ut sometimes the mere magnitude of the disease and-
sometimes the nature of the part and sometimes the tempera-
ment of the patient, one or all, so utterly confound them and
their relations and their order, that either they cannot tell us
what they oiig-ht to tell us, or they tell us what is absolutely
false.

Most frequently it is from the nervous system that the whole
perplexity takes its origin. The nervous sj^stem Avill run on
to such an excess of sympathy as to seem to engross all living-
action and suffering- and allow nothing to aj)pear in the body
but what directly proceeds from itself. It will tyrannize (as it
were) over the vascular system and keep it under, and forbid
it to display by its appropriate sympathies those diseases,
which cannot otherwise be displayed at all. I am well aware
that this is not pathological language. It does not explain
the processes of things, but it may serve to characterise their
results.

In the first of those two remarkable cases which have been
related, the sympathy of the nervous sj'stem was a mixture of
action and suffering but chiefly action, and so intense, so j)lenary
and alone as to draw oif all show and perception of the disease
from the part affected, and to appropriate them to itself. The
physician could see no sign of disease in the heart and the
patient had no feeling of it there. In show and in perception
it was fixed in the nervous centres. The physician saw it and
the patient felt it in the brain and in the spinal nuirrow and
nowhere else. All was delirium and convulsion and nothing
besides.

In the second case the sympathy of the nervous system was
in the way not of action but of suffering. There was no con-
vulsion, no delirium. The intellect was clear throughout and
to the last. This suffering was in the part and not out of it,
but so intense and so all-subduing as to supjsress and keep
down all the proper symptoms of the existing disease. For six
weeks the malady consisted in short paroxysms of extreme pain

314 CLINICAI. MEDICINE. [lECT. XXV.

and anguisli belonging to the heart. And when the malady
was consummated at length in one long paroxysm of three
days, it too was all pain and anguish, still centred in the heart
and still effectually hiding the inflammation, which had been
progressive for weeks and had now reached its accomplishment
in suppuration.

LECT. Xi¥I.] ULCEJ4ATI0N AND ANEUJaSM OF llKAliT. 315

LECTURE XXVI.

-DISEASES OF THE HEARt's MUSCULAR STRUCTURE CONTINUED.

CHRONIC INFLAMMATION TERMINATING IN ULCERATION.

IN i'ARTIAL DILATATION. IN VOSSIHLK RUPTURE. ITS

DIAGNOSIS UNATTAINED. — CASES. — THE SOFT HEART. — THE

FAT HEART. INQUIRY INTO THEIR CLINICAL DIAGNOSIS AND

CLINICAL HISTORY. RUPTURE OF THE FAT HEART.— C^VSES.

Morbid anatomy has disclosed to iis other conditious of the
heart's muscular structure with which we are familiar as results
of inflammation in whatever part of the body they are found ;
such as circumscribed abscesses or deposits of pus ; also idcera-
tions, some having their origin and progress from the pericar-
dial surface inwards, and some from the endocardial surface
outwards.

In the heart it has been sought to demonstrate by dissection
the same forms of aneurism which afiect the arteries. And to
u great extent successfully. Now there is none of them which
do not involve disease of its muscular structure, disease
originating within itself or imparted to it from contiguous
tissues. Sometimes the aneurism has presented an appearance
-as if the disease from which it resulted had belonged to the
muscular structure entirely and exclusively. The endocardium
iind the pericardium have come together at the dilated part, and
no muscular structure has been found intervening between
them. It has been destroyed by disease, and is absolutely
absorbed and gone. Sometimes it has seemed as if it had begun
from inflammation at a spot of the endocardium, which had
softened and destroyed the subjacent muscular layers and so,
proceeding by intermixtures of pus and blood, had ended in
rupture. This is an acute form of aneurism. Sometimes it
has seemed as if it had begun by converting the muscular
substance into a semilardaceous, semiiibrous mass, and pi'oceeded
hy gradually attenuating it and implicating the endocardium

316 CLINICAL MEDICINE. [lECT. XXVI^

and pericardium with it ; and so, by the impulse of the circu-
lating blood, a pouch-like dilatation has arisen and perhaps-
ultimate rupture. This is a chronic form of aneurism.

But the subject of cardiac aneurisms, and of all the forms of
disease which it embraces, is one of great pathological interest,,
and must be studied in the writings of those who have handled
it with the care which it deserves.* It was necessary for me thus-
shortly to direct your attention to some of its prominent
realities, before I could well proceed to consider the living
phenomena connected with them.

Now our clinical acquaintance with these diseases during
life has not kept pace with the knowledge which anatomical
investigation has procured us of them after death. Sometimes-
they have had their beginning and their progress without
awakening in the patient the least suspicion of anything wrong
within the heart. He has had no consciousness of ailment or
suffering, and the fatal consummation has been an awful-
surprise. Sometimes they have been attended with suffering
enough to alarm the patient and by sj'uiptoms enough to enable
the physician to infer damage of the heart, and even to antici-
pate its fatal event, but not to be sure of its nature ; such aa
faltering and failure of the circulation and dyspnoea and
anguish, either constant with occasional aggravations, or alto-
gether occasional and in paroxysms, but, whether constant or
occasional, never attended with any precise auscultatory signs.

But sometimes they have had the accompaniment withal of
precise auscultatory signs, and these have gone to the clear
diagnosis of certain present conditions of disorganisation within
the heart. But then these conditions have been no essential
part of the disease. Auscultation has told of hypertrophy and
general dilatation of the ventricle with certainty enough, but it
has left the partial aneurismal dilatation and the circimiscribed
progressive iilceration and the impending rupture entirely
unsuspected.

* M. Tliuinuia has piu-sued his researches into this subject with
singular industry and ability. He has brought together from all quarters
a multitude of interesting facts, and displayed them and commented upoa.
them in the best manner. — Med. Cliir. Trans., vol. xxi. p. 187.

See an admirable summary of the same sulyect by Hasse in Dr_
Swaine's translation of his Pathological Anatomy, lately published by th&
Sydenham Society, p. 140.

.LECT. XXVI.] ULCERATION AND ANEURISM OF IIEAirr. 317

J. R. was not far short of seventy. For the two or three
last years of his life I knew him well and saw him often, but
never heard him complain of any infirmity. He was an accom-
plished scholar ; convivial and more than habitually cheerful ;
he was even habitually joyous. This I mention to show the
great probability that he really felt nothing of his fatally pro-
-gressive disease. "With such a constant complexion of mind
surely he could not have been a constant sufferer.

On Saturday, the 7th May, 1831, he became alarmingly ill
a,nd I was called to visit him. I found him seated in his chair,
his covmtenance blanched and full of anguish, his breathing
hurried, his skin chilly, and his pulse very frequent and very
feeble. lie spoke in catches, now running on rapidly and now
<joming to a stop, as people do when they have not breath
^enough to carry them through what they have to say. He
muttered something about sinking and fainting.

All this looked near akin to death. And my present busi-
ness was to keep him from actual!}^ ^ying ^7 ai'Y stimulus I
"Could administer.

I collected this history of what he had been lately doing. It
was the time of a general election ; the general election which
was to settle the fate of the Heform Bill, when all England was
in an uproar. My friend had posted down to Northumberland,
and then posted back to Cornwall, had been elected for a
«Cornish borough and then returned to London. He had only
been in town a day or two. On the preceding day he had
suffered severe diarrhoBa and vomiting, and on that very morning
the vomiting had returned.

With this history I conceived simple exhaustion was almost
enough to account for what I saw. I had him put into a warm
bed, and desired that warm gruel mixed with brandy should be
given him pretty frequently, until I saw him again.

In an hour or two he was relieved in his general feelings.
He had thrown off his death-like aspect. But still his respira-
tion was fearfully hurried and his pulse very frequent and very
feeble. And now in running my ear over his chest I heard a
small crepitation at various parts of the lungs. It was upon
the whole of great extent, and proceeding (as it seemed to do)
from the lesser bronchial ramifications I looked upon it as the
<iause of the present dyspnoea. Accordingly I took it as my

318 CLINICAL MEDICINE. [lECT. XXVI.

indication of present treatment and ventured to apply a few
leeches. They [drew but little blood and that very tardily,
owinp^ probably to the chilliness of the surface and the empti-
ness of the cutaneous vessels. Nevertheless he was relieved ;
and during the night a poultice was spread all over the front of
his chest which obtained a little more blood from the leech-
bites, and more relief. With this local treatment I was still
upholding him with cordials and ammonia.

The next day, Sunday, I saw him several times. There was
less about him to occasion alarm, but enough of hurry and im-
pediment in his breathing to call for a large blister. This was
applied to the chest and allowed to remain on twenty-four
hours. It raised very little vesication but acted well as a
rubefacient, and further relief followed.

On Monday this relief was apparent, and when my ear was
now applied to the chest, it found the respiratory murmur
passing through every part of both lungs unmixed with any
unnatural sound except below the scapula). Here the crepita-
tion remained. His skin was now constantly bedewed with a
warm gentle perspiration. Every thing about him was pro-
mising except his pulse, which was still very frequent (much
above 100) and extraordinarily feeble.

On Wednesday', having allowed liim to leave his bed, I
found him up and dressed and seated in his chair, reading
Horace, and as joj^ous as ever, and intent upon going to the
Eton dinner the next week. At this time he believed himself
almost well, and^indeed he looked so. Even his respiration no
longer suffered'~impediment from the exertion of walking about
the room. Still the feebleness of his pulse was extreme and its
fi'equency was not at all reduced.

The two next days, Thursday and Friday, brought him in
his own consciousness and to all appearance nearer and nearer
to health. But his pulse was as weak and as frequent as ever.
It had also something strange in its character which I cannot
describe. In my examinations of the chest from time to time I
had found the heart's impulse exceedingly feeble, yet percep-
tible in a larger space than natural ; and it was feeble still.
All this did (I confess) occns'on me some apprehension, and I
begged upon the^plea of the peculiarity of his case, that he
woull allow me the benefit of consulting- with some other

LECT. XXVI. I I ivOFJiATrON AND ANEURLSM OF 1II5AKT. 31f)

])liysicuui, l)ctbrc I granted liiin llio rights and privileges of
health. Accordingly it was agreed that Dr. Maton should see
him with me on Sunday or Monday.

On the morning of the next day, Saturday, I found him in
bed, and was told that he had passed the night uncomfortably.
lie had himself however been (piite uuconscious of it at the
time, but he was now sensible enough of a more hurried respira-
tion. Yet to my ear the air passed freely and without unnatural
sound through the entire lungs except the lower part of
the right behind. Here there was crepitation, and here I put
on a blister. I saw him again at 8 o'clock at night, when he
was much more at ease in his chest. Three hours afterwards T
was summoned to him on an alarm of his being worse. I went
and found him dead.

The account given me was this. His attendants had been
absent from his room a few minutes. On their return they
found him with his body stretched towards a table by his bed-
side, lying motionless, and holding a cup of barley- Avater in his
hand. They thought he had fainted and endeavoured to rally
him, but without success. He was probably then dead, although,
when I arrived an hour afterwards, they did not seem sure that
he was so.

The body was examined after death. The cavity of each
pleura contained about a pint and a half of clear serum, without
a vestige of inflammation on tlie surface of the membrane.
The lungs were pervious to air and crepitous at every part.
Wherever they w^ere divided, there followed a small quantity
of frothy serum a little tinged with blood. At its posterior
and lower part the right lung was somewhat denser and of a
darker colour than elsewhere. But here too it was quite
crepitous, only, where it was divided, a larger quantity of serum
and more mucus mixed with blood followed than from other parts.

There was no unusual amount of fluid in the bag of the
pericardium ; but the membrane was unusually vascular. The
heart was large, and at one part of its walls (a space of about
two inches) constituting the left ventricle, it was pale and
very soft and gave to the touch the notion of an abscess
approaching the surface from within.

All its cavities were perhaps slightly increased in their
capacity, but its lining membrane presented no visible trace of

320 CLINICAL MEDICINE. [lECT. XXVL

vlisease, save where and what will be mentioned presently. Its
whole muscular structure was flabby, pale, and lacerable, a con-
dition which seemed to arise from its partial conversion into
fat. The fat in some parts occupied the place of the muscular
fibres, the external layers especially ; in other parts it was
intermixed with them, now one and now the other being
predominant.

That portion of the left ventricle already mentioned, which
in its external aspect gave suspicion of an abscess, presented
the following conditions of disease. There the heart was so
attenuated as not to exceed the breadth of a half crown piece,
and rupture or ulceration preparatory to rupture was in pro-
gress. The internal lining was destroyed, and to the rough
surface that it left a large irregular- shaped clot of blood was
adherent. What remained exterior to the clot had lost all
-cognizable organisation ; it hardly cohered together and was
torn like wet paper.

The aorta throughout its course within the chest (for so far
only it was examined) was dotted with little earthy and athero-
matous deposits. The omentum was loaded with fat. The
liver was twice the natural size and full of blood, apparently
not diseased. Its red structure predominated.

This wi^s a case of aneurismal or partial dilatation of the
left ventricle, in which rupture was only just anticipated by
■death. The beginning and progress of the disease were undis-
tinguished by any living phenomena. "When it reached its
•consummation, then indeed symptoms arose, which were striking
and prominent enough. But they had no diagnostic character.
As to the nature of what was going on they told us absolutely
nothing.

Let me give another case : —

H. T. was sixty-three years of age. He had passed a very
laborious life, carrying on an extensive business as a general
medical practitioner; yet he had had no experience of disease in
his own person and had been singularly exempt from bodil}^
infirmity until the autumn of 1844. It was then that he was
suddenly seized with cholera. I attended him and for forty-
eight hours thought him in great peril. Vomiting and diarrhoea,
.an enormous evacuation of fluid like water gruel upwards and
downwards, and severe abdominal pain and coldness and duski-

LECr. XXVI.] ANEURISM OF HEART. 321

ness of the surface, and cramps of the lowei- extremities and a
very feeble and frequent pulse sufticiently denoted the nature
of the disease and its extreme danger. I treated him with
■calomel and opium to restore healthy secretion and subdue pain
on the one hand, and with brandy- gruel to keep him alive on
the other. In two days bile was again apparent in the
evacuations and he was safe for the present.

Yet he did not pass at once into health, but lapsed into a state
of fever. It was fever of low action and continued with increas-
ing debility for more than a week ; when it showed enough of
an intermittent character to suggest the use of quinine. The
remedy was true to its specific virtue. His rigor, heat, and
perspiration never returned, and he was at once fairly on the
way to health again. But he never actually regained the same
perfection of health which he had enjoyed before. His family
told me he was never again the same man. Yet to me his
aspect bore no marks of change. If it had, I must have
<jbserved it. For I saw him at intervals ever afterwards as long
its he lived, being in attendance upon a near relative who
resided with him and was dying of a lingering disease. To his
family however he complained that he was more easilj^ fatigued
than he was wont, and he spoke sometimes of uneasiness in
the chest and palpitation. Yet he made no complaint to me.
He was still bustling about in a carriage or on foot day and
night.

I mention these circumstances because they are not irrelevant
to the event. I saw him for the last time on Friday, Feb. 6,
184:6. He was then (as I believed) in health. On Saturday,
Feb. 7, at half-past 11 p.m. he was seized with illness, and on
Monday, Feb. 9, at half-past 1 p.>r. he died. I happened to be
out of town at the time. All was done that could be done by
Dr. Roots, who saw him during these last thirty-eight hours of
his suffering and of his life. At the house of a patient, whom
lie went to visit late at night, ho was attacked Avith vomiting
iind diarrhoea, and passed at once into a state so full of alarm
that Dr. Roots was summoned to him. That physician has
described to me that he found him apjiarently dying. He was
removed to his own home. And still for the rest of that nig^ht
4ind the whole of the next day and the next night he was
apparently dving. He did not rally in the least degree. All

21

322 CLINICAL MEDICINE. [lECT. XXVI-

ihe stimulants wlilcli were adniinistered just kept the circula-
tion moving and nothing more, until on the following day he
breathed his last at half-past 1 p.m.

In this as in the former case the fatal attack began with'
vomiting and diarrhoea. The coincidence is worth notice.

The body was examined after death by Mr. Wormald, who
has furnished mo with the following description of what was
found.

"On opening the chest, which was very cai:)acious, the peri-
cardium appeared full and tight. Although no great quantity
of liquor pericardii was effused, yet, the heart being large and
all its cavities gorged with blood, the membrane was greatly
distended. White patches on the surface of the heart gave
evidence of past inilaramation, and its substance was of a brown
tint and of a more flabby consistence than the other muscles of
the body. The lining membrane was thickened especially
nbout the base of the mitral valve, where there was a deposit
of a yellow colour. The left ventricle was very capacious and
its walls thicker than natural except at one circumscribed spacfv
This Avas between the two large carnefc columncc. Here, at the
expense of the muscular substance which had entirely dis-
:).ppeared, a cavity was formed large enough to contain half a
vvalnut. The thickened lining membrane was here united by
lymph to the serous covering of the heart, and both together
formed its external boundary. It was diaphanous, and served
for the only barrier which prevented the blood flowing from
the ventricle into the cavity of the pericardium. There was no
laminated coagulum in the aneurismal pouch."

Mr. Wormald. adds, " The liver was large and indurated,
and the terminal branches of the vena cava hepatica were loaded
with blood. There was moreover a slight rujjture of the peri-
toneum covering the liver, which extended to one of the small
hepatic ducts and to one of the branches of the vena porta©
between the lobules. This served to account for some blood
mixed with bile, Avhich was found in the cavity of the
abdomen."

Hero as in the former case rupture was only just antici])ated
l)y death. And in both cases death jjrobabl}^ arose from the
physical impossibility of the heart's maintaining its povrer of
contraction after it had sufiered absolute loss and disconnection

LECT. XXVI.] ANEUKLS.M OF HEART. 323

of its muscular substance, wliilo Its plucc was nevertheless
supplied by other tissue.

This partial dilatation or proper aneurism of the lieart, in
which its muscular structure is especially implicated, is a form
of disease by no means unfrequent, very interesting patholo-
gically and always tending to a fatal event. My business has
been to learn how far we have cognizance of it by living cir-
cumstances ; whether it has any proper clinical history or
clinical diagnosis. And not any such can I find.

But existence may continue until actual rupture take place
and blood escape into the cavity of the pericardium. Death is then
more instantaneous. I have seen some such cases, but I have
not known them until their fatal event has already arrived. It
is hardly necessary to record them for the sake of telling how
this that and the other person fell down dead without any
previous warning. It is not the manner of death that it is pro-
iitable to understand in this disease but the manner of life ; how
life and the great organ of life are affected by it at its begin-
ning and during its progress, and what indications they show
enabling us to minister to it remedially.

The two cases, which I have related, surely do not contain
what we are in search of in respect of the particular disease.
But the}'' contain, nevertheless, matter for reflection. They con-
vey, not a clear understanding, but some conceivable notion,
how life itself and the very attributes and conditions of life
in different organs may interfere to prevent that perfect
knowledge of diseases, which we seek from their symptoms.

Take these two cases and compare them wath the other two
which were given in the course of the last lecture, and see what
they appear severally to denote. The first are cases of acute
inflammation in the heart's muscular structure running on at
once to the formation of pus. They show a disease of such
force and rapidity as by its overwhelming impression upon the
vascular system and the nervous S3'stem to throw all sympathy
into disorder, and utterly to confound the signs by which we
could judge of its existence. The second are cases of chronic
inflammation of the same structure proceeding by little and
little with its destructive process of ulceration. They show a
disease so tardy and so gradual as to convey no perception of
whut it is to the blood-vessels or to the nerves, and to awaken

324 CLINICAL MEDICINE. [lECT. XXVI.

no sympathy in them, and call forth no signs from them of its
existence. Its whole clinical history is comprised in its fatal
event.

The rupture of the heart, which has just been spoken of as
the last result of ulceration, may yet occur independent of it.
Still wherever it has been found, there has generally been at
the same time some peculiar condition of the muscular sub-
stance which might be presumed to favour it. It has been so
soft and loose of texture that it could be pierced through with
the weight of a probe. Or it has been converted into, or greatly
intermixed with, fat.

Not that a rupture has not been found where the texture
of the parts has seemed to offer no natural facilities to its
occurrence, as in the case related by Harvey himself, who found
a lacerated aperture in the left ventricle capable of admitting
the finger through which blood had escaped into the pericar-
dium, the walls of the ventricle being increased in thickness
and strength, while an obstacle existed at the entrance of the
aorta.* Here the heart must have torn itself asunder by the
simple violence of its contraction in contending against the
impediment to the egress of blood from its cavity. This is an
effect which would hardly be thought capable of being thus
produced. But I can well conceive it possible, having seen
one of the recti muscles of the abdomen torn in twain in a
man, who died of tetanus.

The two conditions of the heart's muscular tissue which
have just been mentioned incidentally, deserve a more special
notice. We have seen that rupture is sometimes foimd to take
place for no other apparent reason than because the heart is
soft or the heart is fat. This is a grave result and enough of
itself to bespeak attention to whatever may conduce to it. But
softening of the heart and its conversion into fat have other
serious residts to which they lead.

What is meant by softening is this, a loss of the natural
firmness of the heart's muscular fibres and of their natural
cohesion among themselves, whereby the organ becomes flaccid
and yielding under slight pressure and is easily torn. Being
separated from the body it is unable to maintain its natural
shape. Instead of being round it collapses and becomes
* Harveii Exercit. altera.

LKCT. XXVI.] TFIE SOFTKXKI) HKART. 325

flattened. In its extreme degree of softening it 2:>resents a
loose, soddened, homogeneous mass, which has lost all trace of
fibrous structure.

For the clinical diagnosis of the softened heart you cannot
be referred to any sure signs either auscultatory or non-auscul-
tatory. There are none such as taken alone would determine
its existence. But there are such, as taken together with
certain preparatory and conducive circumstances would make
one almost sure of it ; the circumstances, I mean, which con-
stitute its clinical history. Now what are they ? First there is
fever. For many years I have been accustomed to consider no
single symptom, arising at an advanced stage of fever, to be of
more unfavourable import than an intermitting or irregular
pulse. Though from his general condition I might have no
such expectation, yet the state of the pulse alone had made
me anticipate the patient's death.

In the fever which has prevailed during the last seven or
eight years in the hospitals of London,* and which has been
characterised by weakness rather than strength, and by
petechial eruptions, the morbid appearances after death have
been of various kinds and aj)pertaining to various organs.
Among other kinds there has been a remarkable softening of
textures ; and among other organs, such as the liver, the
spleen, &c., this softening has frequently belonged to the heart.
Now, whatever share a softened liver or a softened spleen may
be thought to have in determining the fate of the patient, a
softened heart may be well conceived to have a greater.

I have been looking over M. Louis's admirable book upon
fever and iind him laying great stress upon the intermitting and
irregular pulse, attesting its formidable import, declaring how
few who have it recover, and stating that he has found in
almost all of those who have had it and have died, a softening
of the heart's muscular structure.

Dr. Stokes of Dublinf has lately been directing attention
to the same morbid condition of the heart among the formid-
able contingencies of fever. And he has done so, with some
novelty in his views of the real nature of the thing itself, with
a more precise notice of its diagnostic signs and (what is most

* The substance of this lecture was given in 1839 and 1840.
t Dublin Medical Journal, March, 183!).

326 CLINICAL MEDICINE. [lECT. XXVI.

important of all) with, tlie discovery, that these contain indica-
tions which may be safely trusted to decide one of the most
difficult points of practice in the manageiucnt of fever. Dr.
Stokes holds this softening of the heart to he a proper and
special effect of fever, and its diagnostic signs to be the impulse
of the ventricle becoming almost or altogether imperceptible,
and the systolic sound at the same time almost or altogether
inaudible. And he considers that the impulse and the sound
together being thus weakened or abolished, whatever in other
respects be the patient's condition, call at once for stimulants
as his only means of safety : and that his safety is insured as
soon as a fairly perceptible impulse and a fairly audible sound
are thiis restored to the heart. The impulse and the sound
thus ceasing and thus returning are, under the circumstances,
diagnostic signs as nearly perfect as can well be conceived.

But there are certain chronic constitutional diseases, in which
the blood becomes corrupt in quality or deficient in some
essential constituent, in its red globules for instance, as in
scurvy or chlorotic anaemia. A pulse deficient in povr^er and
intermitting is among the characteristics of such diseases, and
when death takes place, the heart is found softened.

I have something further to say practically upon this subject
of the softened heart which must be reserved for another
place.

That other condition of the heart, viz. the conversion of its
muscular substance into fat, which acquires an importance from
•'the serious results to which it leads, niaj' be described in a
few words.

The health}' heart is always more or less marked upon its
surface with streaks of white, and this appearance comes from
the deposition of fat in the cellular texture which unites the
serous covering with the subjacent muscular structure. It is
found chiefly where the venao cavoc unite to form the right
auricle ; also at the base of the ventricles and along the line
which marks the boundary between the two, and around the
great blood-vessels as they emerge from the heart. But when
fat is found in more than these situations and in more than
the natural quantity, it is not so much added to the healthy
substance of the heart as existing at its expense and detriment,
and the muscular structure is that wliicli especially suffers.

ILECT. XXVI. J THE FAFTY IIICART. 327

The muscular fibre is sometimes pale and wasted like tliat of a
paralytic limb.

Now the predominance of fat in the heart, whether it lie
superadded to, or intermixed with, its muscular structure, may
be said to constitute a form of unsoundness partaking-, in some
sort, of the character of disease ; moreover, like other unsound-
ness from disease, it naturally leads to unsoundness from dis-
>organisation. The fat heart ends by becoming also a dilated
and enfeebled heart.

During the life of the patient, however, there is (as far as I
know) no sure diagnosis of the fat heart, but a probable con-
jecture only. And even this probable conjecture can scarcely
be made while the heart is siiiipl// fat, and nothing more, but.
must wait until it has I'eached that further disorganisation to
which it naturally tends, namely, dilatation. But, when dilata-
tion is ascertained by its appropriate signs, if valvular unsound-
ness, as its cause, be excluded by the absence of endocardial
murmur, and if a feeble fluttering movement of the heart bo
felt at every part of the precordial region, or beyond it ; and
if, moreover, the constitutional habit of the man be such as to
accumulate fat in all other parts, then it may be taken almost
for certain that fat is especially deposited upon the heart at the
■expense or detriment of its muscular substance. Be it always
remembered, nevertheless, that our inference, however correct
it may turn out, is drawn, not directly from any express
diagnostic signs, but indirectl}'' from coincident circumstances.
No murmur reaches the ear to tell us at once that the heart is
fat. But we know that the heart is feebler and more capacious
than natural. And we know that such, if life last long enough,
is ultimately the condition of all fat hearts. Besides, we
observe that the patient is altogetlter fat, and so we infer the
probability that the heart has not escaped his constitutional
peculiarity.

I purposely dwell upon these points. For one principal
object I have in view is to bring diseases of the heart to a
living test ; to stand by the bed-side, and there see how much
we know of them, and how much we coujectarc, and how,
according to degrees of probability, our conjecture is made,
sometimes little less than knowledge, and sometimes little more
than a guess. Now we are able during life to conjecture

328 CLINICAL MEDICINE. jLECT. XXVf.

a fat heart with such strength of probability that Ave ahnost
know it.

It has been said, that from being fat the heart becomes
dilated. This is its natural tendency, and, if life last long
enough, the event is inevitable. For the present, however, we
will not inquire further in this direction. But there is anothei*
event which is of much rarer occurrence, and may interrupt
its progress to that which is more common. This is its-
ruj)ture.

My own knowledge of rupture of the heart is limited to a
single case. I have, indeed, seen numy a specimen of its-
morbid anatomy; but this is a different thing from knowing
cases. And I have seen some few brought into the hospital
dead or d3"ing, in whom, after death, the heart was found
ruptured; but this, too, is a different thing from knowing-
cases. Only in a single instance have I ever witnessed the
living circumstances attendant upon a rupture of the heart, and
watched the mode and process of dissolution from it. And in
that instance the disease of fatness (so to speak) preceded the
rujDture. To me it was full of instruction, and may be so to-
others ; therefore I will relate it at large : —

Pi. B. Avas in his sixty-first year. For several years he had
been crippled by the effects of gout. He wheeled himself from
room to room in an invalid's chair, and could walk only by the
help of crutches. He had never been intemperate, and was-
now abstemious ; yet his sedentary life had made him fat.

I had known him for more than three years. My first
acquaintance Avith him AAas AA'hile he Avas suffering one of the
severest fits of gout he had cA'er experienced. From that time
forth he put himself under my professional care. I visited
him occasionally, and did my best to Avard off the attacks, to
mitigate them Avhen they came, and to make life tolerable under
his great infirmities. In truth, after I kncAV him, his fits of
gout were much less frequent and much less severe than they
had been before.

One day I was called to visit him, in consequence of an
unusual pain he had been suffering. It occujDied the entire
front of the chest, and j)assed along both the clavicles to the
top of the shoulders, and there ceased, without descending
doAvn the arms. It Avas constant. It had already endured for

LECT. XXVI. J IIUITUEK OF TUE HEART. 329-

a day or two, and had become inucli greater during the last
night. His family, who had watched him, and knew how
naturally uncomplaining and patient he was, had already taken
alarm from something in his looks, which told them that he felt
more than he expressed. His pulse was neither more nor less
frequent than natural. It was hard and incompressible ; but
such was its ordinary character. His bowels were more
torpid than usual. Not clearly seeing the nature of the present
distress, I contented myself with ordering a mustard poidtice
to the chest, and prescribing some cordial aperient medicine.

On the next day I found that not the smallest relief of pain
had been obtained. And now he described more distinctly its
severity, w^hich had kept him sleepless and incapable of lying-
down during- the entire night. I examined his chest. The
lungs admitted air freely and equably. The respiratory mur-
mur was perfect. The heart beat over a somewhat larger
space, and with somewhat more force than natural^ but Avithout
unnatural sound. He looked more subdued than on the pre-
ceding day. But no new symptom had arisen. His complaint
was still of pain, and of pain only. It looked like angina
2)ccto)-is but for its permanence. With some slight hope that it
might have a relation to his gouty habit, I ordered half a
drachm of vinum colchici and a drachm of paregoric to be taken
immediately, and again in six hours.

To my great surprise, on the following day I found him
quite free from pain. He had taken the first dose of colchicum
and paregoric, and then the pain began gradually to leave him.
He took the second at bed-time, and passed a comfortable night.
The medicine had acted upon no secretion. It seemed to have
produced no sensible effect beyond the suspense of the pain, if
that really was its effect ; only it had left a slight nausea.
Conditionalh% in the event of the nausea first passing away, I
directed him to take the same dose of colchicum and paregoric
at night. The nausea did cease, and the remedy was taken.
The next day he cheerfully reported that he had passed a good
night, and had been and still was free from pain. But the
nausea had returned. This state of things admonished me to
desist from medicine altogether. The nausea prohibited the
further use of colchicum, and the total absence of pain left
nothing to be done at present but to wait and to watch.

530 CLINICAL MEDICINE. [lECT. XXVI-

Together with the events of this important case, let us have
regard to the article of time. It was Monday when I first saw
the patient, and now it was Thursday. Already, for two nights
-and for a part of two days, the pain had been suspended, and
it was about to be suspended for a night and a day longer ; a cir-
cumstance which in the sequel will appear quite unaccoimtablc.

Well ; his state was now so hopeful that my attendance on
the following day seemed unnecessary. And, enjoining a total
•abstinence from medicine in the meanwhile, I appointed to visit
him again on Saturday.

But on the next day, Friday, I was suddenly called to him.
It was six P.M. I foiuid that, about an hour before, the pain
had returned with far greater severity than ever. He was
-deadly pale, and from the centre to the extremities of his body
he was cold as marble, and streaming with perspiration ; but his
pulse was of a good strength, and his heart Avas contracting
regularly and forcibly, and now, for the first time (according to
my observation), with a loud systolic murmur, audible in the
prtccordial region, and not in the arteries. I administered a
large dose of opium with a;ther and ammonia. Visiting him
again in an hour or two, I found the pain unabated, and his
pulse beginning to sink. I staid with him through the night,
still giving at intervals opium and relihcr and ammonia, and
-appljdng external warmth, but all to no purpose. Still th'.-
pain did not lessen. Still he looked and he felt like a corj^se,
he was so pale and so cold. At four in the morning (Saturday)
the pulse finally ceased to be felt in the arteries, while yet the
heart was perceived by the ear to move, but not by the hand.
In tliis state ho survived seven hours longer, until, with his
mind clear to the last, he died at 11 a.m. Let me add, what I
shall not soon forget, that this good man endured eighteen
hours of mortal agony with wonderful patience and resignation.

Upon examination after death, all the interior structures of
the body were found more loaded with fat than its external
appearance would have led me to expect. We looked only
superficially to the abdomen, where we found nothing remark-
able but a vast accumulation of fat within the mesentery. Our
-attention was chiefly directed to the suspected seat of disease —
the chest. Here the lungs were perfectly healtliy. The heart
was a good deal larger than natural as a whole, and incased

LECT. XXVI.] KUITURJ: 0|- TilF. IIKAIH'. 331

in fat. It was upon its rig-lit side that tlic fat was accumulated
to the greatest amount, and its muscular substance was evcry-
■s\-here very Haccid and \-cry thin, and became thinner and.
thinner as you approached the apex, where it was reduced, to a
mere line. Yet, thin as it was, it was quite healthy in colour,
and preserved all the visible characters of muscle without any
intermixture of fat. The fat was all exterior to it. The capacity
of the right ventricle was notably larger than natural. Its
internal lining was stained, of a dcej) red. Its orifices were
free, and its valves health}'-. On its left side it was less covered,
with fat. Here the ventricle was considerably dilated. The
muscular substance was considerably hypertrophied. It pre-
served its healthy character, both of coloilr and consistence in
the external parietes ; but in the septum it was pale and soft,
manifestly in consequence of fatty degeneration. In the
septum, at its posterior juncture with the parietes, there was an
oblique rent passing through it from ventricle to ventricle. On
the side of the left ventricle it was an inch and a half in length;
on the side of the right it jnst opened at a point. In truth,
while we were examining the right side, the rupture passed
undiscovered. The orifices of the left, as of the right ventricle,
were quite free, and its valves healthy. The coronary arteries
contained, some atheromatous deposits, but were quite pervious.
The aorta was healthy as far as its arch. It began to be
studded with atheromatous and earthy matter in its descending
portion.

When this case occurred to me, it brought to my recollec-
tion a specimen of rupture of the septum preserved, in the
museum of St. Bartholomew's. The patient from whom it was
taken did not die in the hospital. I did not sec him ; but I
took some pains at the time to ascertain the circumstances of
his death from those who witnessed them, as w^ell as those cir-
cumstances of his life which could be fairly ascribed, to the
state of his heart found upon dissection ; and. the following is
the record which I then made :— -

A gentleman, sixty years of age, inclining to corpulence,
had for several years been liable to occasional attacks of severe
inflammation of the lungs, requiring copious blood-letting for
their cure. In the month of February, 1829, having suffered
such an attack during the previous winter, and been relieved in

332 CLINICAL MEDICINE. [lECT. XXVI.

the usual manner, lie began to experience a new complaint.-
This consisted of pain beneath the sternum, suddenly coming
and going, attended by pain or numbness down one and some-
times down both arms, and by something more than pain, an
indescribable anguish, generally within the chest. The attack
would seize him as he walked along the streets ; whereupon he
would stop, turn into a shoj), rest a Avhile, and then proceed.
The weather was foggy at the time, and to it he was willing to
ascribe his new complaint. But the attacks continued to recur
when there was no foggy weather to account for them. In the
month of April he sulfercd two ; one on horseback, the other
in bed and at night.

One day, towards the end of the same month, he was sud-
denly seized with this pain beneath the sternum and down both,
arms. It was severe and agonizing, beyond what it had ever been
before : and immediately his aspect became that of a dying-
man, pale and purple about the lips ; his pulse very frequent,
and hardly perceptible. In this condition, by the help of
stimulants, he was still kept alive three days.

The state of the heart, as it was found after death, is thus
described in the catalogue of the museum : " The cavity of the
right auricle is larger than natural, and its membranous lining-
is thick and opaque. The tricusj^id valve is thickened, and its-
lining opaque. The aortic valves are a little thickened, and
there is a soft matter deposited beneath the lining of the aorta
just above the valves. The coronary arteries arc thickened^
and there is bony matter deposited between their coats. A
rupture of the septum dividing the ventricles has taken place
near its union Avith the posterior wall of the heart, by which a
free communication is made between the two ventricles. On
the side of the left ventricle the opening is about two inches
in length, and of a semi-lunar form. On the side of the right
the opening is much smaller and rounded."

From the description which I have quoted, it does not
appear that the septum had undergone any morbid degenera-
tion, which could be thought to give it a greater liability tO'
rupture than any other part of the heart's muscular structure.
But such degeneration was so remarkable in the case which had
fallen under my own observation, that I could not help desiring
a more accurate examination of the preparation at St. Bar-

LECT. XXVI.] RUPTURE OF THE HEART. 333

tliolomcw's, if lifter the lapse of soveuteeii years it were indeed
possible. Mr. Paget and Dr. Orinerod undertook it for me, with
the aid of the microscope, and have obligingly communicated
to me what they were able to make out : " There was much oil
swimming at the top of the jar. The texture of the heart was
somew^hat soft. On the parts about the rupture were many
drops of oil, and hereabout the muscular tissue was evidently
disorganised, for it appeared as irregular gramdar cords, with-
out any transverse strioc, which elsewhere were well-marked.
But there was no distinct fatty degeneration of the muscular
tfibres."

It appears then that in this, as in the other case, the
septum had undergone a morbid change of structure, rendering
it more liable to suffer rupture. But the change was not
exactly of the same kind in the two cases.

334 CLINICAL MEDICINE. [lECT. XXVII.

LECTURE XXYII.

rXSOXJNDNESS OF THE HEART FROM DISORGANISATION. — HYPER-
TROPHY. AT ROPII Y. DILATATION. CONTRACTION. WHAT

THEY ARE IN THEMSELVES, AND IN THEIR COMP.INATIONS.

THEIR CLINICAL DIAGNOSIS, HOW FAR ATTAINABLE BY

AUSCULTATION. THEIR CLINICAL HISTORY CONTAINED IN PRIOR

DISEASES CONDUCIVE TO THEM. THESE DISEASES MAY BE

I'.ITHER IN THE HEART OR IN OTHER PARTS OF THE BODY.

OBSERVATIONS UPON THEIR CLINICAL HISTORY, AS CONTAINED
IN PRIOR DISEASES OF THE HEART.

We come now to those affections of tlie heart v/hich may be
usefully classed together xmder the name of unsoundness from
disorganisation. They consist in alterations of size and shape
and bulk and capacity, and are the same which are commonly
denoted by the terms hypertrophy, atrophy, dilatation, and
contraction. And I shall continue to use the same terms. I
only designate them, as a ckm, by this name of " unsoundness
from disorganisation," that it may help us to keep in mind the
important truth, that disease properly so called does not enter
into the actual process of their formation.

Disease or any unsoundness left by disease within the heart
may indeed furnish their original and conducing cause. But
the things themselves are still different. Adhesion of the peri-
cardium and thickened valves and strictured orifices may be
first the spring and then the motive, the never-ceasing and
often the ever-increasing motive, of the heart's contracted or
dilated cavities, of atrophy or hypertrophy of its muscular
substance. And thus in the end nothing is more common than
for the same heart to present a complex of imsoundness from
disease, and of un?oundness from disorganisation. Still (I
repeat) the things themselves arc different. And their very
relation to each other, and their frequent xmion in the same
subject make it tlie more necessary to remember that they are so.

IJX'J'. XXYll.] JlVrEKTKOlMIV, ATROPHY, ETC. 335

It was but fit, ]iowev(^i', llmt in tlio order of our ])rococdi:ig'-
^vc should preserve the link of connection -which pathology has
])ointed out between the two ; and treat of that first Avhich
]iaturally comes first, and then of that which naturally follows.
So much for the sake of arrangement. But now, when wc arc
come to these latter affections, to these forms of unsoundness
from disorganisation, you will find that it is with them as it is
v/ith every thing in the shape of disease or disorganisation
throughout the bod}', viz. that while each according to its kind
lias one mode or process of formation which is peculiarly its
x)wn, it may have twenty different causes capable of originating
it and conducing to it. Thus there is one process of hyper-
trophy and one of atrophy, one process of dilatation and one of
contraction of the heart's cavities in all cases. But the cause
may be prior disease of the heart itself in one case, of the aorta
in another, of the lungs in a third, deformity of the chest in
a fourth, and the morbid quality of the blood in a fifth.

Hypertrophy and atrophy, dilatation and contraction, seem
to carry with them their own meaning. What they are might
almost be left to your general conceptions. Still some short
<lcscription is needed to bring the things themselves fairly before
the mind, ere we proceed to give a practical commentary ujoon
them, and to dwell upon them more at largo.

Hypertrophy is a simple augmentation, and atrophy is a
simple diminution of bulk and consistence in the heart's
muscular substance. In hypertrophy its muscular substance is
more red than natural, its carncfo columncc are increased in
thickness, and its proper fibrous texture is every where more
strikingly manifest, while there is no interstitial deposition of
matter new in its kind. In atrophy its muscular substance is
less red than natural, its carneao columnae less developed, and its
proper fibrous texture less distinguishable. But there is still
the appearance of muscle shrunk and withered as if from an
insufficient supply of nourishment.

Of dilatation and contraction really nothing more can bo
said by way of description than that the one consists simply in
increased capacity, and the other simpl}'- in diminished capacity
of one or more cavities of the heart.

But these forms of disorganisation affecting the muscular
substance and the cavities of the heart bear relations to one

336 CLINICAL MEDICINE. [lECT. XXVII.

another, which should be noticed. Hypertrophy and atrophy
seldom occur while the cavities retain their natural capacity.
And dilatation at least, if not contraction, is seldom found with-
out augmentation or diminution of bulk in the muscular parletes.

Upon this subject, of the capacity of the heart's cavities
:iind the bulk of its muscular substance and the relation which
one bears to the other, some explanation is needed to prevent
erroneous notions from the language often employed. Simple
dilatation is indeed often sjjoken of, implying augmented
-capacity of the cavities, while the muscular parietes still retain
their natural thickness. Now consider, and you will see that
the heart in a state of dilatation cannot preserve its normal
'thickness on any other terms than these, viz. that in exact pro-
portion to its expansion and while that expansion is going on,
something should be continually added to the bulk and substance
■of its muscular fibres. Hence what appears to be and is often
called simple dilatation, is in fact and ought to be called dilata-
tion with proportionate hypertrophy. And what appears to be
£caA is often called dilatation with moderate hypertrophy, is
in fact and should be considered dilatation with excessive
hypertrophy.

Again consider, and a^ou will see that the heart when its
cavities are dilated and its walls thinner than natural need not
on that account be considered in a state of atrophy. Here there
lias been a lengthening and expansion of the muscular fibres,
but no diminution of their substance. In obedience to a pres-
sure from within they have yielded and spread themselves over
a larger space. They have lost nothing. They have suffered
no atrophy : only they have not, as in the former case, ex-
perienced a proj)ortionate hj^pertrophy. They have not, in
proportion as they have lengthened and expanded, received
additions to their bulk.

But at the bed-side we must be content to know less than
we know anatomically, and to use terms which designate just
what we know and no more. Practically and in relation to
living circumstances the terms commonly employed, when I was
a student, to denote these complex disorganisations involving
the cavities and muscular structure of the heart, were very
good. They regarded the ventricles more especially. The
terras were active and passive dilatation.

LECT. XXVII.] IIYPERTROPIIV, ATKOrHY, ETC. 337

They do not reach aniitoinical differences, but they vouch
for us much as our diagnosis can really compass during the life
of the patient. Active dilatation implies a more capacious
ventricle with such a change of its muscular structure as ih
calculated to augment its power ; whether this change be a
non-apparent but real (what I have called a proportionate)
hypertrophy, or an apparent and so an excessi\e hypertrophy.
Passive dilatation implies a more capacious ventricle with
such a change of its muscular structure as is calculated
to diminish its jiower ; whether this change be a real
atrophy or an expansion and elongation only of its mtiscular
fibre.

Active dilatation may appertain to every cavity of the
heart simultaneously; and so may passive dilatation. But
sucb occurrences are rare ; for one cavity being naturally more
liable to this species of dilatation and another to that, it most
trecpiently happens that specimens of both conditions are foimd
in the different cavities of the same heart.

Contraction of the heart's cavities is a much rarer patho-
logical chanffc than their dilatation ; and when it occurs, it has
hj'pertrophy or atrophy as less certain accompaniments.

A few years ago pathological anatomy had come to regard
two particular forms of disorganisation as the natural opposites
of each, other, and was fond of using names chosen on pur-
pose to mark their contrast. These names were — eccentric
liypertrophy, and concentric hypertrophy'. The eccentric
was that in which, the cavity goes on expanding and en-
larging ; and the concentric that in which, it goes on closing
and diminishing, as the muscular substance becomes thicker and
thicker.

But it turns out to be more than doubtful whether this last
combination have a real existence during life and whether it
do not arise during the act of dissolution and result from the
very mode of dying ; in fact whether concentrically hypertro-
phied hearts be not hearts, which " being more or less hyper-
trophied, death has surprised in all the energy of contraction."
This combination of thickened walls and diminished cavities
has been found in those who have died violent deaths and in
executed criminals. Dr. Budd met with it in many instances
of sudden death from cholera. After maceration the cavity of

22

338 CLINICAL MEDICINE. • [lECT. XXVIT.

tile ventricle, whicli before would not contain a blanched
almond, became of its natural capacity.*

Still there is no doubt that during- life the cavities of the
heart suffer diminution of their natural capacitj'. There arc
peculiar forms of preceding unsoundness from disease which
lead to pccidiar forms of subsequent unsoiindness from dis-
organisation. They produce contraction of one cavity and
dilatation of another, or of all the rest. Thus the left ventricle
being diminished in capacity, the left auricle is enlarged ; and
sometimes not the left auricle only but the right auricle and
ventricle also ; nay more, some or all the blood-vessels leading
immediately to and from the heart maybe at the same time dilated
except the aorta, which is contracted. Stricture of the mitral
orifice is calculated to produce it all. L^nsoimdness of the
mitral valve from disease may lead to this vast amount of
unsoundness from disorganisation.

Of the forms of unsoundness from disorganisation described
by morbid anatomy those which I have noticed are the
principal in their ; kind. They are also the most frequent.
They embrace moreover the pathological consequences of all
the rest, and therefore may stand representatively and virtual!}''
for them all ; and so be taken for the text of our practical
commentary.

First then for their clinical diagnosis. This Is chiefly an
affair of auscultation. In our first lecture after describing the
natural sounds, impulses and resonances of the heart, we con-
sidered their variations of degree and extent. And then wc
enquired what it was that such variations whether of excess or
defect, according as they are differently combined in Individual
cases, must be taken to denote ; and we found in them the
express auscviltatory signs of these forms of disorganisation
which have just been described, namely, dilatation or contrac-
tion of the heart's cavities and thickening or attenuation of its
muscular structure. I refer you back to what was then said
instead of repeating it in this place.

It must be admitted however, upon this matter of the

capacity of the heart's cavities and the bulk of its muscidar

substance, that accuracy of diagnosis is attainable only in

respect of the ventricles. Of the auricles auscultation (as far

* Budd, in Med. Chir. Trans, xxi. 296.

ILECT. XXVir.] lIVPRRTROI'ItV, ATROI'IIY, ETC. 339

as I know) conveys no direct iutclligcuce. What tlieir state
may Lc we arc left to conjecture from other and indirect signs,
and chiefly from the previously ascertained state of the
ventricles. And of the ventricles themselves, when the
■question is of their capacity and their bulk, the left is far
more within the reach of accurate diagnosis than the right.
And this more accurate diagnosis of the left may come from
auscultation alone, while the less accurate diagnosis of the
right comes partly from direct auscultation of it, and partly
from certain conditions of the venous circulation and from the
previously ascertained state of the left.

We come next to the clinical history of these same dis-
organisations of the heart, of its hypertrophy and atrophy, its
dilatation and contraction. By clinical history here as else-
whei-e 1 mean the assemblage of living phenomena which
experience has found to be prior and preparatory and conducive
to tliem.

Truly it is a vast subject this of the clinical history of the
•disorganisations in question ; and truly it must be a vast
experience which embraces it, and peculiar difficulties lie
naturally in the way of it. And it is well you should be
antecedently aware of all this, that you may be better able to
exercise a cautious judgment upon what can only be laid before
you summarily and concisely.

Always then keep in mind the great difference there is
between acute diseases and chronic disorganisations of the
heart as to the way in which we come at our knowledge of the
conditions conducive to each, respectivel}^ How much further
will each man's own observation go in the one instance than in
the other I By the time he has seen a few cases of endocar-
ditis and pericarditis, he has an experience of his own of all
the reputed conditions out of which they arise. The cases
themselves have been entire cases. He has watched them from
first to last. Their conditions have been such as strike the
senses and emerge rapidly ; and he has seen them as they have
emerged. But he may have gone on witnessing cases of hyper-
trophy and atrophy, of dilatation and contraction half his life,
and still found that his own experience has not yet certified to
him all the reputed conditions conducive to them. Few,
perhaps none, of the cases which he has witnessed have been

340 CLINICAL MEDICINE. [lECT. XXVII.

entire cases. And observution runs sadly to waste when it is
made upon cases piecemeal.

Again consider, wlien we have to deal witli what comes
first or comes early in a series of pathological changes, as endo-
carditis and pericarditis usually do, that then we have seldom
far to seek for the conditions that lead to it. The few steps
of our inquiry are tolerably easy and sure. AVe have perhaps
only to examine the circumstances attending the last transition
from health to sickness that took place some two or three days
or two or three weeks ago, and there we find them. But when
we have to deal with what comes last or comes late in a series
of pathological changes, as hypertrophy and atrophy, dilatation
and contraction usuallj^ do, then it must be by a more far-
seeking, by a more difficult, and a more fallible research that
we are to make out the conditions that lead to it. It will not
be enough to note some recent transition from health to disease,
but (what is a far harder task) we must make good the links
which have been coupling disease with disease and disorganisa-
tion with disorganisation for years and years together.

In seeking to make out the clinical history of these affec-
tions we must be content with a mixed inquiry, practical in
part and pathological in part, made up of our own exj^erience^
and of others' experience, and of what we know or believe,
from the nature of the thing, either must be or is likely to be.

Hypertrojohy and atrophy of the heart, dilatation and con-
traction of its cavities seldom, perhaps never, take place but
where some disease or unsoundness has previously existed,
either in the heart itself or in other parts of the body, from
which they are derived as a natural and necessary consequence.
I say perhaps never, because the instances are very few hv
which such disease or unsoundness is not either already known
during life or discovered after death ; and in those very few
where it is not apparent either during life or after death, the
probability is greater that we had not penetration enough to
find it out than that it did not exist.

Now, such being the case, they can hardly be said to have
any clinical history which is properly their own. It must be
greatly involved in the clinical history, whatever it may be, of
any prior disease or unsoundness within the heart or without it>
from which they are derived. Hence all that has been said of

IJCCT. XXVIl.] llYl'KirrROlMIV, ATKOI'HV, ETC. 341

each and every disease of the heart which we have hitherto
described, of endocarditis and pericarditis and the permanent
unsoundness which they leave behind, of thickenings and trans-
formations of the valves and stricture of the orifices, also of
inflammation and softening- and degeneration of the muscuhir
substance, what was it but a long recital of the conditions })rior,
preparatory or conducive to these forms of disorganisation which
we arc now considering ? Thus a large part of their clinical
liistory has been amply set forth already, although it was not
specified as such at the time. But a largo part remains to be
considered, viz. that which is found in prior disease or unsound-
jiess of other parts.

For the sake, however, of marking some important practical
considerations, I Avish to revert shortly to the connexion between
prior forms of disease or of unsoundness from disease in the
heart itself, and its subsequent forms of unsoundness from dis-
<jrganisation. The clinical history of the second is contained
within the first, A\-hich has been pathologically conducive to
them.

Now, such clinical history of disorganisations of the heart
may, according to the nature of its prior diseases, be plain and
manifest and most instructive, furnishing a living illustration
■of their pathology ; or it may be obscure and uncertain ,
revealing little or nothing of their pathology during life and
leaving it to be made out by what ma}^ hajopen to be detected
after death. Take a survey of cases and see how they bear out
this view of the matter.

In many cases of hypertrophy or atrophy, dilatation or con-
traction, we are apt to learn, upon inquiry, that there was long
ao'O an attack of acute rheumatism and that then the heart
suffered detriment and from that time forth it had never been
right. Furnished with this notable fact and knowing the
heart's present condition we are enabled to read the cases
backwards from their end to their beginning and see through
all their course both clinically and pathologicallj'. AVe now
find hypertrophy or atrophy of the heart's muscular substance
and dilatation or contraction of one or other of its ventricles.
But before these there was adhesion of its pericardium or stric-
ture of one or other of its orifices ; and one or both of them
still remain. And still before these there was inflammation of

342 CLINICAL MEDICINE. [lECT. XXVIL.

the pericardium or iuflammation of the endocardium or of both,,
aud the effects of one or of both were imperfectly repaired.
And still, even before the inflammation or coincident with it,
there was a rheumatic fever. It may have taken one or two,,
five or ten, fifteen or twenty years to bring residts to their final
accomplishment in different cases. But where there is sO'
notable a fact to beg-in with and so clear a succession and
development of pathological consequences from first to last, the
matter might be simplified and the truth would be preserved and
our conception of it assisted, if the whole were looked upon as
one continued malady.

There are no cases belonging to the same class which have
their clinical and pathological history so satisfactorily made out
as these. Other cases, in which prior disease of the heart and
its unrepaired effects are summed up in these same forms of un-
soundness from disorganisation, give comparatively obscure
tokens of their origin and progress. "VVe find in them no
notable fact which came first, and was manifestly exordial to all
that followed. And the want of it spoils the completeness of
their clinical history.

Call to mind what has been said of chronic diseases of the
endocardium, producing cartilaginous, atheromatous and earthy
deposits. How uncertain and conjectural were our notions of
any living conditions preceding, preparatory and conducive to
them. There is large experience of these forms of imsoundness
from chronic disease co-existing together with the forms of
unsoundness from disorganisation, which we are now consider-
ing. And whenever this is the case, we venture to conclude
that the conversion of the valves into cartilage, atheroma or
bone came first, and that the hypertrophy or atrophy, the
dilatation or contraction followed. Pathological reasoning tells
us that it must be so ; although living conditions do not mark
the time at which one is superadded to the other.

Call to mind too what has been said of the aneurismal
heart and of the fat heart, and how obscure was their clinical
history. Obscure also must needs be the clinical history of the
hypertrophied or attenuated and dilated heart when they follow
them as their natural consequences.

But something yet remains to be mentioned which, having
a prior existence in the heart, may and does lead to its dis-

LECT. XXVII.] HVl'KliTlJOI'HV, A'IKOl'IIV, KTC. 343;

organisation ; something-, wliicli has not vstrictly the nature of
disease, although disease may follow it, and which I have not
vet found a fit place for describing. I niean accidental injury.
I wisli then now to direct attention to (what I will venture
to call) shocks of tlie heart, in which it suffers hurt from
violence. From this hurt or from disease which follows it, or
from both, disorganisation, especially in the form of hyper-
trophy and dilatation, is apt to follow. Thus these shocks of
the heart become part of the clinical history of its disorganisa-
tion and claim to be considered in this place. The subject (as
far as I know) has nowhere been treated of. My own
acquaintance with it is scanty and imperfect, but still enougli
to show me that it has very important relations, both patholo-
gical and practical. Being however of a distinct nature it
htd better be reserved for a separate consideration in another
leiture.

344 CLINICAL JIEDICINE. [lECT. XXVIIf.

LECTURE XXVIII.

XJNSOUKDNESS OF THE HEART FROM DISORGANISATION SOMETIUES
TRACEABLE TO AN ACCIDENTAL SHOCK WHICH IT HAS JUS-
TAINED. — THIS SHOCK A FART OF THE CLINICAL HISTORY
OP ITS UNSOUNDNESS.

Accidents sometimes lielp to illustrate tlie operations and effects
of disease as poisons illustrate tlie oi^erations and effects of
remedies.

The following' case was furnislied to me by Dr. Bence Jones; —
" A stableman twenty-eight years of age was admitted iito
St. George's Hospital. He was suffering, and had sufferedfor
twelve months, severe palpitation of the heart, and was ablt to
mark distinctly the moment of its commencement. It was one
day just after running a horse down the yard to show off his
paces to a purchaser. He had never had acute rheumatism. His
lips were blue, his breath short, and his left side painful. He
had a dry cough. His bowels were confined and his urine free.
It was ten weeks before his admission that his cough and
dyspnoea had begun to be particularly distressing. Auscilta-
tion found dulness in the pnxicordial region over an exteit of
four inches square, the heart's impulse increased and its first
somid prolonged with a low blowing (endocardial) mumur
over the aortic valves, and its second sound indistinct. H( was
bled three times under the urgency of his cough and dyspoea.
These however continued to increase. Five weeks afte: his
admission his legs became codcmatous, and in two weeks nore
he died.

" On examination after death three pints of fluid were foind
in the right pleura, and the heart enormously large. In leigth
it reached from the second to the eighth rib, and across the lase
of the ventricles it measured six inches. The left ventricle s^as
moderately hypertrophicd and very largely dilated. The miral
valve was healthy, and the aortic was slightly thickened, ,nd

JLECT. XXVIU.J ACCIDENTAL SHOCKS TO HEART. 345

«ioroovci' Lad sufl'ered rupture of a peculiar kind. One of its
septa was torn away from its attaclimcnts, and thus two of its
pouclics were reduced to a single irregular one. The right
ventricle was dilated, but both the auricles preserved their
natural state. In the ascending aorta and in its arch there
were atheromatous deposits. The liver was very large, and the
.«pleen and the kidneys were healthy."

Cases running parallel with this are not common, but yet
frequent enough for most medical men of experience to have
met with one or two. Upon some violent efibrt, such as rowing,
leaping or boxing, or some violent succussion by an external
force, a shock is felt by the heart as of an injury done to it ;
pain, palpitation, and perhaps a sense of approaching death
may follow. But death does not then actually take place. And
the ultimate result is a good deal according to the treatment
which the patient meets with at the time.

I have seen such accidents with such immediate effects
terminate in simple palpitation or excess of impulse. This
•simple palpitation has been constant ibr a few months, and then
it has been occasional only upon some known excitement, and
then it has ceased altogether. Or it has been permanent and
has never afterwards ceased, and then in process of time there
have arisen moreover the sure signs of h^^pertroph}" and dilata-
tion. Again I have seen such accidents terminate in palpita-
tion with an endocardial murmur, and both have been perma-
nent, and in process of time the sure signs of hypertrophy and
dilatation ha^e been superadded to them.

After we have been engaged for some years in the practice
x)f our profession we come to have a great experience infragmcnts
of cases. We see abundance of cases at their commencement or
in their progress, of which we never witness the termination.
But such experience is not without value. All I know of the
results which follow sudden shocks proceeding from accident
and severely felt and resented by the heart, such as simple
palpitation and palpitation with an endocardial murmur, palpi-
tation enduring for a time and then ceasing altogether, palpita-
tion abiding permanently and after a while having hypertroj)hy
and dilatation added to it, all this has (I confess) come to me
as yet chiefly from fraginents of cases ; cases, of which I have
not seen the whole or witnessed the event.

346 ■ CLINICAL MEDICINE. [lECT. XXVIII.

But a single entire case often furnishes the key to many
fragments of cases. Thus Dr. Bencc Jones's case serves to
exphiin others which have not run on to the like fatal
result.

I was called to see a gentleman in the prime of life and
having the aspect of perfect health, whose heart was heating
with excessive impulse and with a loud systolic endocardial
murmur, audihle in the pra?cordial region, but not in the arteries.
lie was not incapacitated for moderate exertion, but found it
needful to be very cautious what he did and how he moved, lest
his palpitation should run on to a painful degree. I satisfied
myself that the left ventricle had imdergone a certain amount
of hypertrophy, and that the mitral valve was unsound. But
how came this serious detriment of the heart in one so young
and otherwise so healthy ? Had he suffered an acute rheuma-
tism ? No. Had he suffered any attack of fever or inflamma-
tion in which his heart was known to have been involved ? No.
But he had suffered an accident. A twelvemonth or more ago
lie had experienced (what I have called) a shock of the heart in
rowing. A perilous state of things immediately ensued. He at
once sought the advice of Dr. Chambers, who treated him ac-
cording to the kind and severity of his symptoms, which were
those of acute inflammation, of endocarditis. He bled him and
brought him under the influence of other antiphlogistic remedies,
and so saved his life. But he did not procure a perfect repara-
tion. Permanent unsoundness was left behind ; unsoundness of
a valve, which though it proceeded from accident was tanta-
mount to unsoundness from disease, and like it was ready to pro-
duce unsoundness from disorganisation. In truth now after
the lapse of a twelvemonth it had produced hypertrophy of the
left A^entricle.

If in this case we inquire the nature of the injury suflered
by the heart at the time of its first shock. Dr. Jones's more
complete case must supply the key to it. And thus we cannot
avoid believing that it was a rupture of the mitral valve.

Two more years have past since this gentleman was examined
by me. I know that he still lives and bears the appearance of
health, but still displays the same symptoms referable to the
heart, and suffers the drawbacks xiijon his freedom of bodily
exertion, which belong to imsoundness of the mitral valve and

LECT. XXVIII.] ACCIDENTAL SIHH KS 'lO IIKAUT. 347

hyportropLy and dilatation of tlie left ventricle, hut all modevato
in dcg-ree.

It is pretty plain, in what point of view these shock.s of the
heart, attended with present structural injury, should be practi-
cally regarded. Any structural injury, inflicted by violence^
forthwith has disease apjjendant to it. And, if it be of an
external part and within our reach, we can both treat the injury
and treat the disease, the one b}" our manipulations, the other
by our remedies. But if it be of an internal part and beyond
our reach, we can only treat the appendant disease. The rupture
of a valve by shock of the heart forthwith has inflammation
appendant to it. Yet "s^'e can only treat the inflammation and
must leave the rupture to itself. Thus, respective to their
treatment these shocks of the heart are to be regarded in the
light of disease.

Not less are they to be so regarded, respective to their
results. Our treatment, though it be only addressed to the
appendant inflammation, may be followed by the perfect repa-
ration both of the inflammation and the injury : or our treat-
ment may save life, but fall short of efiecting a complete repa-
ration, and permanent unsoundness may remain. How much
this unsoundness is made up of the half-repaired injury and how
much of the half-repaired inflammation we cannot tell. But in
process of time hypertrophy or atrophy, dilatation or contraction
are added ; and thus these cases, though they originated in
accident, at last fall practically into the category of unsoundness
from disease leading to unsoundness from disorganisation.

Now the eases, in which a present hypertrophy or atrophy,
a dilatation or contraction are clearly traceable back to a shock
of the heart, though they are not frequent cases upon the whole,
are peculiarly interesting. And those, to which reference has
just been made, may be taken to represent the most interesting
of their kind, for they seem to display very intelligibly the
manner in which events come to pass. The original shoch of
the heart involved an injur}' of one of its organic textures and
the rupture of a valve : and the efiects of that injury or of its
appendant inflammation or of both, being incompletely repaired,,
became the manifest cause conducive to its disorganisation.

But there are eases in which we have the present disorgan-
isation of the heart and the prior shoch of the heart, yet we do

348 CLINICAL MEDICINE. [lECT. XXVIU.

oiot clearly see the intermediate agency by whicli the one has
been brought out of the other ; we have no sure evidence that
the >ihocl- was attended at the time by any real injury of its
■xirganic textures.

►Something, nevertheless, must have then occurred to make
the lieart palpitate ever afterwards and ultimately lead to its
organic unsoundness. But what could it be ? Can no other
textures of the heart suflFer mechanical injury and even rupture
■except its lining membrane and valves ? It is mainly the
nmscular structure which is involved in the change of bulk and
x'hange of capacity constituting the eventual unsoundness.
Maj' it not be the muscular structure which suffers the j)rimary
injury ? Indeed it may be, and it probably is ; but the fact is
.utterly incapable of proof. Enough has been said in the two
last lectures to show how strangely covert and secret and beyond
the reach of clinical observation are all the chief diseases and
rinjuries which primarily affect the muscular structure. It may
suffer acute inflammation and purulent deposits among its fibres ;
■it may suffer chronic inflammation and penetrating ulceration ;
it may suffer a complete disruption of large extent, and yet put
forth no distinctive signs of one or the other during life. That
the heart's muscular structure is penetrated with pus in one
•xjase, ulcerated through in another, and rent in twain in a third,
are facts which are left for death to disclose. And, if its greatest
diseases and its greatest injuries thus lie hid during life, are
.those of smaller account, such as partial ulcerations or a strain,
or any kind or degree of mechanical hurt which may be con-
ceived to come from a shock, likely to make themselves more
•surely known ?

But these shocks of the heart, though nobody knows Avhat
-they really are, yet have emergencies which need to be treated
at the time of their occurrence. And treated they have often
been successfully in different measures. In some life has been
.saved, no small thing surel}' ! And in some, moreover, evil
. consequences have been altogether prevented, and in some post-
poned. I have a few more fragments of cases worth relating
for the sake of what they seem to teach practically. I will tell
them as shortly as they can be told.

A young man between twenty and thirty, who had lived
rvery hard in the Avay both of incontinence and intemperance,
was seized in the midst of some vigorous pastime (I think it

LECT. XXVIir.] ACCIDENTAL SHOCKS TO IIEAUT. 349-

was rowing) with sudden pain of tlio lieart and excessive
impulse and the sense of ai^proaehing- death. His phj'siciaii,
ministering to present emergencies, bled liim largely. And
the relief that followed the remedy was so marked and manifest
to the feeling of the patient and so instantaneous that he was
sure it saved his life. But thougli his life was saved, abiding
pain and abiding palpitation still kept it in jeopardy, for they
incapacitated him for exertion during many weeks, and in tin-
meantime occasionally rose to the same excess and were accom-
panied by the same sense of dissolution as at first, and needed,
and were relieved by, the same remedy.

Now, it was not until after the lapse of two or three months
from the original attack that this person fell under my observa-
tion. He had then returned to the business of life, but he was
ill able to fulfil it. Palpitation of the heart was still a check
upon all bodily exertion and all mental effort. I have now
known him and seen him at intervals for more than two years,
and still the palpitation remains. I find simple excess of im-
pulse without any unnatural sound, but I am not certain that
the heart has undergone any degree of hypertrophy. Twice
or thrice during these two years the palpitation has run on to
excess, and a death-like feeling has come over him. He is
engaged in a profession. But whatever he does, business and
pleasure, and eating and drinking, are all under the restraint
of continual watchfulness for the sake of moderating the palpi-
tation of his heart.

What was the nature of the injury originally incurred and
what is the kind of malady at present suffered in this case I
cannot tell ; but whatever they be, they distinctly proceeded
from a shock of the heart more than two years ago.

Take another case. A young man twenty- two years of age-
was with his regiment at the Cape of Good Hope. He had
been extremely intemperate and incontinent in his habits for
two years and more, and he had suffered occasional palpitation
of the heart. One night he went to a ball, and danced till
morning, and then plunged into a cold bath and appeared on
parade. But he found himself brought to a stand by violent
palpitation. He felt as if his heart had suffered injury, and
he was incapacitated from duty from that very hour. But he
had not then the death-like sensation, which is apt to come
with the shock. Yet he did not escape it. For about a fort-

4350 CLINICAL MEDICINE. [lECT. XXVIII.

night afterwards tlie palpitation, wliicli liad never ceased, sud-
denly ran on to extreme violence, his lips turned blue, pain
seized the left side and he thought himself dying. He was at
once largely bled, and felt sure that the bleeding saved his life ;
iind three days afterwards he was cupped with great relief.
His life however was still considered to be in jeopardy for a
month. When he could be safely removed he was sent to
England. It was five months from the time that the heart
may be supposed to have received its shock, before I saw him.
He had been sixty-eight days at sea, and in England for a
month. The quiet of the voyage had brought down his palpi-
tation almost to nothing, and, when he reached England, he
believed himself almost well. But his palpitation had
returned and had been increasing for the month he had been
at home, although he had been passing the life of an invalid.
I found him suffering simply paljjitation. I thought the
sounds of the heart loud, but otherwise quite natural.
Moreover, I perceived a slight bulging of the ribs over the
prascordial region, but I could not satisfy myself of any undue
extent of pnrcordial dulness, and upon the whole I could not
make up my mind whether there was, or was not, an}- degree
of hypertrophy.

This young man continued to visit me at intervals of about
a fortnight for three months. He was enjoined and (I believe)
he practised the greatest care to avoid every thing which could
be thought capable of conveying an injurious impression to the
heart either through the body or through the mind. Never-
theless the heart did not cease to beat with some excess of
impulse at all times, which very moderate bodily exertion and
very moderate application of the mind to business were sure to
increase. x\nd at the end of the three months I had more fear
of hypertrophy than at the beginning.

The issue of these two cases, of the one after more than
two years, and of the other after nine months is still in
suspense. The issue to be apprehended is progressive hyper-
trophy and dilatation. In both, I consider that life was saved,
and that these disastrous terminations have been thus far post-
poned, and may possibly be prevented, mainly by the treat-
ment fortimately employed at the time of the shock, and by
the extreme care and discipline to which the patients have ever
since been subjected.

LECT. XXVIII.] ACCIDENTAL R]IOCK'< To irEAli'l". 351

Such trcatiucut and such care and disciph'no arc sometimes
successful in the largest sense, as the following case will show.
A friend of mine, then two or tliree and twenty years of age,
was dinino- at some distance from home when a messensrer
€ame to tell him that his father's house was on fire. Oft' he set
as fast as he could. And running down Oxford Street he came
in fearful collision with a man who was running in equal
haste the other way. Down they both fell. My friend
recovered himself. What became of his antagonist he never
knew. He himself crawled home with some difficulty. Fur-
tlier than this I am not informed what was the immediate
ofl'cct of the shock. But from that time he was seriously ill
for many months. ITis symptoms were altogether referable to
the heart, and consisted of excessive impulse and pain. He
w^as attended by the late Dr. Baillie, who bled him largely.
The remedy must be considered to bespeak the nature of the
■emergency, and the belief of some serious injury or disease
sustained by the heart. After the lapse of many months he
was allowed to return to the business of life. He had then
lost his constmt palpitation. But for a few years it was wont
to return painfully upon occasions of excitement. At length
ho lost it altogether ; and lived five and twenty years after the
shock and the perilous illness, ^^■hich followed it, active!}'
engaged in a laborious profession.

Let me add a notice of two more cases w' hich occurred when
I was a student at the hospital. A man passing through Spa
Fields one night was unmercifuUj'- beaten and plundered, and
thrown into a ditch and left to die. Die, however, he did not,
but lay there he knew not how long ; for he was insensible.
The next day he was found and taken home. He was disabled
by the bruises he had received, and by palpitation of the heart
and dyspnoea which he had never complained of before, and
was never again able to return to his ordinary occupation.
After some months he was admitted into St. Bartholomew's,
dropsical, and bearing all the symptoms which denote hyper-
trophy and dilatation of the heart. He soon died, and his
heart was found of a size which was almost incredible. All its
muscular substance was enormously amplified, and all its
cavities enormously dilated, its pericardium and lining mem-
brane and valves free from disease.

^Nearly about the same time a poor fellow died in St. Bar-

352 CLINICAL MEDICINE. [leCT. XXVIII,

tliolomew's, who siiflFerecl the same sj-mptonis during life,
namely, dropsy and excessive palpitation and dyspnoea, and in
whom were found the same conditions of the heart both in what
it did, and what it did not, display of unsoundness after death,,
namely, hypertrophy of the muscular substance and dilatation
of the cavities, with the pericardium and the internal lining-
perfectly healthy. And this man ascribed his mortal complaint
to a paroxysm of anger, and referred its origin distinctly to a
particular occasion. lie was naturally irascible ; and one day his-
wife having offended him in a transport of rage he seized a knife,
and was just plunging it into his OAvn throat, vfhen the poor
woman rushed upon him, disarmed him, and disappointed
his purpose. Some neighbours came in and secured him
imtil his rage had burnt itself out. But from that day he
had always been sensible of a palpitation of the heart, which
had o-radually increased until it incapacitated him for work.
Then he became dropsical, was admitted into the hospital and
soon died. All was the work of not many months.

But is it quite certain in these cases that the hypertrophy
and dilatation reallj- came from a material injury done to the-
heart at the time of the shock ? In neither of them did the-
heart present the visible traces of any such injury as could be
conceived to proceed immediately from violence. Still I do not
know that any thing short of absolute disruption must neces-
sarily leave the characteristic marks of itself ever afterwards.
It is conceivable that the injury itself might not be of a per-
manent nature, and yet abide long enough to lay the foimdation
of permanent disorganisation. Further it is possible that, in
these same cases, causes might have been found in other parts
of the body (for such it will presently appear there often really
are) entitled to a share in producing what was found in the
heart. Nevertheless the shock, that had been suffered in both
cases, was a remarkable part of their clinical history. The
patients themselves constantly ascribed to it the origin of all
their malady. We cannot therefore exclude it from our con-
sideration, and may venture, without speculating further upon
what cannot be proved, to regard it as in some manner power-
fully conducive to the hypertrophy and dilatation of the heart,
and to the fatal event.

LECT. XXIX.] I)ILA1'ATI<)\ nF AOIJTA. 353

LECTURE XXIX.

CLINICAL HISTORY OF 1 HE IIKAKl's LNSOUNDNICSS FROM DIS-
ORGANISATION CONTINUE]). CAUSES EXTERIOR TO THE HEART

CONDUCIVE TO IT. DILATATION AND CONTRACTION OF THE

AORTA. CERTAIN DISEASES OF THE LUNGS. — CURVATURE OF

THE SPINE AND DEFORMITY OF THE CHEST. GICNERAL DIS-
EASE OF THE ARTERIES. COINCIDENT DISEASES OF DISTANT

TARTS. LIVER. SPLEEN. KIDNEYS.

]>EAR ill mind that wc have been considering the clinical hisfori/
of the heart's organic unsoundness after it is already brought
within the scope of clinical diagnosis. This clinical history we
have thus far found involved in its own prior diseases or its
prior accidental injuries, Avhich are tantamount to diseases,
and their unrepaired effects. The heart itself then lias thus
far appeared to contain the conditions conducive to its dis-
organisation.

But the clinical history of the heart's organic imsoundness
takes a wider ran^e. Conditions conducive to it are found,
beyond the heart itself, even in other organs both near and
remote, and in the constitution at large !

Of these conditions themselves, in the mode of their opera-
tion upon the heart, so as to alter its structure, some are easy,
and some are difficult to understand, and some in the present
state of our knowledge, quite inexplicable.

Dilatation of the aorta is often found coincident with active
or passive dilatation of one or several of the heart's cavities.

Cases, however, are met with, where dilatation of the aorta
subsists without the heart having suffered any change in its
natural structure. The question, therefore, naturally suggests
itself, whether the coincidence, when it does occur, really and
truly exhibits the relation of cause and effect ?

Cause and effect ! These terms are allowed, indeed, in

23

354 CLINICAL MEDICINE. [lECT. XXIX i

pathological reasoning; but its svibject-matter seldom admits
their use in that strict sense which philosophy would require.
In patholog}^, so many counteracting circumstances, known and
unknown, are perpetually liable to intervene, that it can haixUy
ever be said of anything that it exerts a power out of which
some other thing must ncccsmrihj proceed. The present state
of our knowledge will seldom permit us to affirm more than
that a certain morbid action, or morbid structure, has its ten-
denc}?- to such and such a consequence — not its sure termination
in it.

Thus a dilatation of the aorta may naturally tend to dilata-
tion of the cavities of the heart, while circumstances may be
perpetually interfering with the result. Of these, some are
easily appreciated.

A dilatation of the aorta may exist, but the still and seden-
tary life of the individual may postpone or prevent the full force
of the injury from being felt by the heart. Again, since all
harm resulting to the heart from the aorta must be through the
medium of the current of blood passing from one to the other,
it will be more or less likely to take effect according to the
greater or less plenitude of the blood-vessels ; and thus in the
present case of dilated aorta, the full and plethoric will, there
is reason to believe, suffer disorganisation of the heart sooner
and more surely than the pale and exsanguine.

Disorganisation of the heart from a dilated aorta being of
tardy growth under all circumstances, and being still liable to
be further postponed by accidents, it cannot happen contrary
to our expectation that death should often take place and
exhibit the one without the other.

But by what agency does the heart become disorganised in
consequence of a dilated aorta? It is, probably, by its own
extraordinary efforts to overcome a virtual impediment to the
circulation. Blood being immediately poured from it into a
larger space than natural, requires from the heart an augmen-
tation of its motive impulse.

I believe that a dilatation of the aorta is more apt to dis-
turb the action of the heart, and ultimately to injure its struc-
ture, when it occurs as a general enlargement of the vessel
over a certain space, than as an abrupt expansion in the form of
a sac ; and I believe also, the nearer it is found to the origin

LEcr. XXIX.] coNTitAtrnoN oi'^ AoirrA. 355

of tlio aorta, tlio more capable it is of producing- these
effects.*

But an unnatural narrowness of the aorta no less than its
dilatation there is reason to place among- the causes conducive
to disorg-anisation of the heart.

I have not been able to lay my hands upon the notes I took
of a case illustrating the point in question, which occurred
■several years ago. The circumstances, however, were so strik-
ing-, that I can trust my memory, I think, for the accuracy
of the detail.

A little boy, between four and five years old, and very puny
of its age, was brought to the hospital in its mother's arms.
Its countenance betrayed great anguish, and its respiration was
•exceedingly hurried ; and there was no part of the chest where
the heart could not be felt acting with enormous impulse ; at
the same time the pulse at the wrist manifested nothing extra-
•ordinar}'. There was, I recollect, no remarkable blueness of
tthe lips, or other evidence of impediment to the passage of
blood through the lungs : the hurried breathing seemed to
depend upon the simple vehemence of the heart's action.

What could be the nature of the case ? The age of the
■child first made me think of congenital malformation. : but all
the malformations I was acquainted with were such as had the
efiect of mixing venous and arterial blood, and distributing it
throughout the body. But here no such effect was ajDparent.
jVIy next impression was, that the heart had become dilated in
consequence of an adherent pericardium ; but the mother could

* The aorta was found greatly dilated in a certain case, cj[uite from its
-origin to its arch, and thickly interspersed with bony scales, like drops of
white wax which had cooled ; and the heart itself so thickened in its whole
mnscular structure, and so dilated in all its cavities, as to equal the heart
■of an ox. — Morgagnl, xviii. 28.

The aorta, in another case, was greatly dilated ; quite from its origin to
the neighbourhood of the emulgent arteries, and rigid tlirough the whole
■of this tract, from the deposition of bony lamella? ; and all the parietes of
the heart thickened ; and both ventricles, especially the left, mucli dilated.
Ibid. 30.

In another, the aorta was dilated from its origin throughout half its
descending portion through the chest, its internal lining being discoloured
and thickened, and furrowed, and exhibiting here and there some bony
lamella) ; while tlie heart had both its ventricles much enlarged in tlu'ir
■capacity, and somewliat thicker than natural in their parietes. — Ihid. 3-1.

356 CLINICAL MEDICINE. [lECT. XXIX.

give no account of any rheumatic attack which the child had
ever suffered, or of any acute disease whatever which had
fallen expressly upon the chest ; on the contrary, she had not
observed the disorder to arise at any particular time, nor could
she trace it to any particular cause. The child, she said, was
healthy for some time after its birth, and it was not until after
it was weaned that the "strange heatuir/" within its chest was
noticed, which had continued gradually to increase.

A few days only elapsed between its admission into the hos-
pital and its death. The manner of its death was peculiar : it
suddenly became pale, and the heart, which an instant ago
struck forcibly against the ribs, was only just perceived to
move ; the impulse was gone, and dissolution was looked for
the next moment ; but in this state, pale and cold, yet appa-
rently sensible, with the heart just moving, and air passing in
and out of the lungs, as it were mechanically, the poor child
survived during a whole day, and then it ceased to exist.

UjDon dissection the heart was found enormously enlarged,
and every cavity greatly exceeding its natural capacity. To
what extent, or in what parts its muscular structure was thick-
ened or attenuated, I do not recollect ; but the most remarkable
circumstance which attracted our attention was this — that the
aorta, and all its principal branches, while they were entirely
free from disease, were by more than one-half less than their
natural capacity.

The case upon record which bears the nearest resemblance
to that just related, is one reported by Meckel, in the History
of the Eoyal Academy of Berlin, for the year 1750. The
subject was a puny girl, 18 years old. No further account is
given of her history than that she had been, from time to time,
subject to joalpitation and anguish, and trembling of the limbs,
from her infancy to her 14th year, and thenceforward the pal-
pitation and anguish had become constant and more severe
until her death.

Upon dissection the heart was found enormously enlarged,
and the aorta, throughout its whole course, especially through
the chest, and all its principal branches, marvellously narrowed.
The heart had both its ventricles dilated, and their substance
more soft than natui'al ; it had its auricles also dilated, but the
/fft to a degree far greater than Jiny other cavity. It was

LECT. XXIX.] CONTRA CTIOX OF AORTA. 357

capable of containing the prodigious quantity of twelve ounces,
while the coi'responding ventricle only contained four. The
aorta was not more than half the diameter of the pulmonary
artery.

From the history of these cases, it is evident that the nar-
rowness of the aorta and its branches was a congenital malfor-
mation, and that enlargement of the heart was a natural and
necessar}^ consequence, and perhaps even an indispensable
condition for the continuance of life.

But this narrowing of the aorta need not be so extensive as
that which has been described, and yet may have the same
effect upon the heart in influencing the dilatation of its cavities.
A very limited and partial narrowing may, according to its
situation, produce a mechanical impediment, of which the stress
may fall upon the heart equally, or almost equally, with one
which is more extensive. In a case where the aorta is repre-
sented to have been ^'contracted to an amazing narrowness"
near the heart, the heart itself is said to have been dilated to
an extent "■ never before seen," the dilatation appertaining
especially to the rigiit auricle and ventricle.* Surely a con-
traction of its calibre in this situation would serve as efiectually
to impede the exit of blood from the heart as if it belonged to
the whole aorta and all its branches. But when contractions of
the aorta occur in situations more remote, there is much less
certainty of any injury resulting from them to the structure of
the heart.

Among the causes exterior to the heart capable of producing
its disorganisation, we must not omit the consideration of those
which are seated in the lungs ; for none are better authenti-
cated. Owing to the peculiar structure of the lungs, and their
proximity to the heart, inflammation and its consequences
(eff"usions and depositions) may well be conceived to offer
impediments to the transmission of blood, which the heart must
feel and resent. And they really do so. The efi'ects upon the
heart, however, are partial only, and limited to the right side,
and consist of dilatation of its cavities.

Whatever diseases of the lungs can so change their structure
as greatly to limit the free space for the transmission of blood,
if they be diseases of frequent occurrence, must, one should
* Mor"a"ni, xviii. 6.

359 CLINICAL MEDICINE. [lECT. XXIX..

suppose, be all well kiioMTi as frequent, and almost certain,
causes of this partial dilatation of tlie heart. And in the sub-
jects of pulmonary consumption, where the natural structure of
the lungs is often obliterated to such an extent that hardly
any free space remains for the transmission of blood, one might
expect to find the most numerous instances of such dilatation.
But, in point of fact, it is rarely found in combination with
tubercular disease of the lungs.

Now, it is not the quantity of impediment within the lungs-
themselves taken absolutely, but relatively to the quantity of
blood required to circulate through them, which becomes thc'
occasion of the heart's dilatation. Thc impediment may be-
A'cry great ; so great that one Italf of the lungs may be solidified,
and yet there may be no dilatation of the right cavities, if at
the same time the mass of circidating blood be diminished by
one-half. This is actuallj^ the case in pulmonary consumption.
During its j^rogress there are operations at work in the consti-
tution at large, which are daily deducting something from the
general mass of blood ; so that in the end, though there be but
little of the lungs in a pervious condition, yet that little is still
adequate to transmit thc little blood which remains in the cir-
culation ; and thus, though the absolute impediment in the
lungs is very great, there is no detention of blood in thc right
cavities of the heart, and no dilatation of them.

It is remarkable in this disease, how those symptoms whichi
are considered to be of the most fatal omen, seem to arise out
of an express provision of nature for prolonging the duration
of life. The hectic perspiration, the occasional diarrhoea, the
sputa, the languid powers of nutrition, all tend to keep down»
the current of blood to that measure which can obtain an easy
passage through the lungs. On any other terms the joatient
would die of sufibcation suddenly, and at an earlj' jicriod of his.
disease.

Nevertheless, it is still the tendency ox obstruction in the-
lungs to produce accumulation of blood in, and consequent dila-
tation of, the right cavities of the heart ; although in phthisis
jDulmonalis, where the obstruction is the greatest, such dilata-
tion is rarely met with, owing to peculiar conditions of thc
general circulation. The influence of causes seated in the
lungs in producing dilatation of the right side of the heart, is..

LECT. XXIX.] DKFOrtMITIICS OF CRKST. 359

best sccu ill diseases which; while they create great impediment
to the transmission of blood through them, may nevertheless
subsist for years without much injury to the general health,
without si^ecial injury at least to the nutrient functions of the
body, and without any notable diminution of the general mass
of blood.

fSuch are the diseases commonl}^ called adhmatic, diseases
which differ from each other in their essential nature, but agree
in certain common effects, such as in impeding the respiration
permanently or at frequent intervals ; in permitting the con-
tinuance of life for years ; and in not diminishing the general
bulk of the body, or the general mass of the blood, but some-
times even allowing both to increase. According to my own
observation, the subjects of asthmatic diseases furnish the most
frequent instances of dilatation of the heart from causes seated
in the lungs.

Deformity of the chest, resulting from curvature of the
spine is justly reckoned among the causes capable of producing
disorganisation of the heart, especially active or passive dilata-
tion ; or, it may bo, dilatation both of one kind and the other
CO- existing in the several cavities of the same heart. The whole
chest being distorted and narrowed, and the lungs straitened
and imprisoned, and the heart itseK displaced and the aorta
tortuous, and the liver bearing hard with its external pressure,
lead upon the whole to as large an amount of hurtful encroach-
ment of organ iipon organ as can possibly be conceived. And
this encroachment cannot be without mechanical impediment ;
and this impediment cannot be without hurt and hindrance,
first, to the functions, and then to the structure of such organs
as the heart and lungs.

Of the causes, then, exterior to the heart capable of pro-
ducing its disorganisation, these are they which are the most
acknowledged and the best understood ; dilatation and contrac-
tion of the aorta ; certain diseases of the lungs ; and deformities
of the chest. They seem all to bring about their common
result by the one way of impediment to the free passage of
blood from the heart into the arteries.

That active and passive dilatations of the heart may result
from impediments to the course of the circulation, either real or
virtual, is one of those conclusions in pathology most certainly

360 CLINICAL MEDICINE. [lECT. XXIX.

established. But the theory, which is unquestionably just
within certain limits, has been enlarged to an extent which
neither facts nor right reason will verify ; for some have dis-
covered in an aneurism at a remote part of the aorta, or in a
plug of coagulated blood in some of its immediate branches,
positive impediments capable of being felt and resented by the
heart, and thus necessitating its disorganisation. And others
have been too ready in resolving into cirtual impediments many
merely speculative modes of morbid action, which belong to the
capillary blood-vessels.

With respect to a real mechanical impediment, it is probable
that, in order to become a certain and effective cause of disor-
ganisation of the heart, it must be situated either in the heart
itself, or not very remotely from it. I certainly never met with
a case myself, and I find none upon record, where, the heart
being disorganised, and no disease being found at any of its
orifices, and none in the lungs, and none in the thoracic aorta,
there was still any mechanical impediment at a remoter part of
the vascular system to which its disorganisation could be fairly
ascribed. When any such distant impediment exists, every
collateral artery, given off between the obstructed or contracted
portion and the heart, will furnish it an additional security
against injury ; for how far soever the obstruction is felt from
the seat of the impediment, so far these vessels will and must
dilate, and will thus, in proportion to their number, re-establish
the freedom of the circulation, and effectually secure it.

With respect to impediments arising out of morbid actions
in distant parts, I cannot so easily accommodate my mind to an
hypothesis as to believe all that is pretended concerning them.
I find depositions of lymph in the cellular texture of a limb,
constituting what is called a solid a^dema ; I find tubercular
depositions in any organ, such as the liver ; I find even simple
inflammations of distant parts seriously insisted upon, as if they
were well authenticated causes of disorganisation of the heart
when they have hajjpened to exist together with it. And the
theory of mechanical obstruction is brought in confirmation of the
fact. For, say the theorists, where there is inflammation, there
must be spasm of the extreme vessels, and spasm is tantamount
to obstruction. And again, where there is effusion or deposi-
tion of any kind, there must be pressure upon the neighbouring

LECr.XXIx] MECHANICAL OBSTRUCTIONS TOCIIiClJLATl(>N. 361

blood- vessels, and pressure must produce obstruction, partial or
complete, according to its degree.

Xow, by parity of reasoning, there is no conceivable sort of
morbid action in any part of the body, which may not be con-
sti'ucd into an obstruction of the blood-vessels, and thus conjured
into a possible cause of disorganisation of the heart.

But, to dwell only on those specified conditions of other
parts of which there is no doubt that they hold the place of
causes naturally conducive to tlio heart's organic unsoundness,
namely, dilatation and contraction of the aorta and certain
pulmonary diseases and deformity of the chest, has our know-
ledge of them, as such, any real practical use 'i Indeed it has.
For these causes, conducive to its organic unsoundness, are ever
at work, covertly or manifestly, in beginning, furthering, and
accomplishing it. They are parts of its living pathology.
Being parts of its living pathology, they belong to its clinical
history so far as during life they can become objects of our
knowledge. And in part they can, and in part they cannot .

Dilatation and contraction of the aorta are reserved for
•detection after death. It is not until then, that they are found
■to have been covertly working out the heart's unsoundness
-during life. Thej^ did not, and could not enter into its clinical
histor3\

But the peculiar forms of pulmonary disease are cognizable
•enough during life, and are manifestly seen all along bearing
hard upon the heart, and the heart's unsoundness is seen all
.alon<> growino- under them. In the treatment of such affec-
tions of the lungs we never disregard what may happen, or
what has already happened, to the heart. The lungs, beside
what their own impeded functions require for themselves, are
perpetually suggesting to us indications, how best to prevent
or postpone or palliate the expected or the actual and growing
unsoundness of the heart.

Deformity of the chest too is cognizable enough. But it is
a thing of degrees. It may be extreme from birth. And then,
the heart in its first growth may suffer itself to be so wa^csted
from its true place and shape, and from its true bulk and
•capacity, that its vital functions become impossible, and the
child quickly dies. Or it may be such from birth as to make
ithe heart grow shapeless, monstrous, and out of place, and yet

362 CLINICAL MEDICINE. [lECT. XXIX»

allow it to continue the offices of life for years, provided care
be taken to avert from it all casual influences of an injurious
sort. Thus the very deformed often reach the age of puberty,
and then die ; or under a penal vigilance of all occasions^
accidents, and circumstances that can harm them, they some-
times attain a moderately advanced period of life.

In almost all cases, where life continues with extreme
deformity of the chest, the organic unsoundness of the parts
within is complex. The lungs and the heart suffer equally ;
and, beside the common causes conducive to the uusoimdness of
both alike, each is continually helping on the unsoundness of
the other.

Unquestionably a numerous class of cases still remains, in
which the heart is found with its cavities dilated, and its
muscular substance in a state either of hypertrophy or of
attenuation, while at the same time nothing is discovered to
which this disorganisation can be expressly ascribed, either in
the heart itself, or in the thoracic aorta, or in the lungs, or iu
deformities of the chest ; and we are left to seek in the con-
dition of more distant parts, or iu the habits or casualties of
the patient's life, or in his previous diseases, for something-
which will bear to be suspected as the cause or occasion of
its production. These cases must now shortly engage our
attention.

In the phenomena of health and of disease, there are things
concerning which the present state of our knowledge is totally
inadequate to explain how they are or why they are : yet of
many such things Ave may still know more than their bare
existence. We meet with peculiar organic diseases, and we
may be at a loss to explain the exact physical process of their-
production ; yet we ]nay remark many circumstances so con-
stantly preceding or accompanying them, that avc can hardly
doubt that there exists between them some kind, although we
know not what kind, of physical alliance. It has never
occurred to me to meet with active or passive dilatation of the
heart in a body otherwise perfectly sound. The concomitant
diseases have not indeed had, at all times, a strictly accountable
connection with it ; yet the}- have, in a manner, rendered its
existence more intelligible.

The coincidence of disorganisation of the heart, especiallj''

LECT. XXIX.] OIJSTIUXTION BY JHSEASED AKTEUIE.S. 863

of its liypertropliy and dilatation, ^Yitl^ the marks of chronic
disease extensively diHuscd tliroughout the arterial system, is
very common. The internal lining oi' the arteries, here and
there, in various situations, and upon the wliole to a great
extent, has lost its transparency, and become a little thickened,
and dotted wiih. cartilaginous and atheromatoiis and bony
deposits ; but nowhere has its change of structure been such
as could be thought capable of producing injury simpl}^ by
mechanical impediment. And this inay be all that is found in
the body to account for the heart's unsoundness. But this
mere beginning of disease in the arteries, which is indeed a
small matter when we see it in single blood-vessels, becomes a
great matter, and capable of great eifects when it spreads itself
throughout the bod}^ It may well be concei>'ed enough to
make itself felt by the heart.

In looking over such records of cases as I possess, it is
• remarkable in how large a proportion of them I find this con-
dition of the arteries coincident with hypertrophy and dilatation
of the left ventricle. And this, I have said, may be all that is-
found in the body to account for the heart's unsoundness.
But oftentimes there is this and much more than this. We see
that the disease of the arteries has reached a more onward
stage, and made larger and more extensive deposits of cartilage
■and atheroma and bone, while the liver and the spleen and the
kidneys are found enlarged and granulated ; and the trans-
parent membranes, as the pleura and peritoneum, are thickened
and opaque. These are evidences and efi'ects of chronic in-
flammation, and have a pathological connection one with
.another. And it is strange, if they have not also a connection
with the disease difi'used throughout the arteries ; and it is
strange, moreover, if they have not all a connection with the
hypertrophy and dilatation of the heart.

But in specvilating upon diseases and disorganisations of
other parts as the causes conducive to diseases and disorganisa-
tions of the heart, we must be cautious that we do not invert
the real order of things. For the order of causation will be
found to run as often from the heart to other organs as from
other organs to the heart.

Must we, however, be content to speak of these things as-
customary coincidences only, or must we try and prove the-

■364 CLINICAL MEDICINE. [lECT. XXIX.

essential nature of tlie relation which seems to bind the several
sirgans together in one pathological link, and the heart among
the rest ? The truth is, we can only speak of them as coinci-
dences. "We are not sure that we possess a single element
towards a proof of the process how they come to pass, and how
ihey are brought together. "We want new facts to help us.

And indeed this is the age for finding out new facts, and
testing their truth under various aspects. But the time has not
-come for putting them all in order, and assigning them their
•right places, and building up systems with them.

The greatest single pathological fact disclosed during the
present centurj^, is that which Ave owe to the research and
■sagacity of Dr. Bright — the murbid imsoundness of the kidneys
-attested by the presence of albumen in the urine. It is a
fact largely suggestive of things beyond itself, of new elements
H^f disease, and new modes of morbid action. With whatever
forms of disease, and in whatever organs of the body, the
physician has to do, he will sometimes meet with this fact in
them all. And assuredly wherever he finds it, it holds an
important pathological place, though the present state of our
knowledge may not enable us to say what that place is.

It is easy to talk disparagingly of the best things. It is easy
to talk of this, merelj^ as of one more incurable malady, added
-to the many which were too M'ell known already. But do we'
not judge of present diseases, whence they are, what they are,
•and whither they tend, by the nature of the coincident facts
belonging to their clinical history ? Now coincident with how
many and with what various classes of disease do we not find
this momentous fact, this sure index of granulated kidney,
•idbuminous urine ?

There are dropsies, and yet at the same time no known
impediments of the circulation to satisfy their mechanical
theor}', or that theory of them which is best understood. But
their great coincident fact is albuminous urine.

There are haemorrhages, bronchial and pulmonary, with
•sound heart and sound lungs ; intestinal haemorrhages, with
■soimd abdominal viscera. But their great coincident fact is
albuminous urine.

There are inflammations of external surfaces, as erysipelas ;
•<md of internal surfaces, as peritonitis and pericarditis, arising

LECT. XXIX.] ALBUMINUKIA A^'I) HKAliT DISKASi:. 36.'i'

suddenly, yet without any known sudden impression. Jiut the
great coincident fact is albuminous urine, forming part of their
clinical history ; and it is strange if it also does not form pari
of their essential pathology.

To come to particular organs, as tlic brain : some of it&
smaller affections will put on a peculiar character of perma-
nency and intractability without further evidence of harm to it»
own structure ; vertigo and pain will be abiding and incurable-
and incapacitating, while the urine is albuminous. And some
of its graver affections will come and go and admit of a present
relief, which is unusual when harm has befallen its own struc-
ture ; convulsions and apoplexies appear and disappear and
yet are ultimately fatal, the chief concomitant circumstance
which attracts our notice being albuminous urine.

And so too of the heart, it will palpitate without apparent
cause inherent in itself ; it will undergo organic unsoundness-
still without cause belonging to itself or to other parts, sa\e
what can be inferred from the presence of albuminous urine.

But the kidneys being unsound, and betraying their un-
soundness by albuminous urine, what is the common agency by
which these multitudinous effects are brought to jjass ? Hom
does disease befal many organs simultaneously, or how is il
handed from organ to organ, from blood-vessels to solid viscera,
from the liver and the kidneys to the brain and the heart ^ Is
it through the blood itself and a poison in the blood Y Pro-
bably it is. Pathology will perhaps settle the question after
the lapse of 3'ears. But in the meantime practical medicine
must condescend to humbler things, and to seek for causes, if
they deserve the name, out of the body. Prior to diseases, to
their diagnosis, their history, and their treatment, prior to them
and beyond them, there lies a large field for medical observa-
tion. It is not enough to begin with their beginning. There
are things earlier than their beginning, Avhich deserve to be
known. The habits, the necessities, the misfortunes, the vices
of men in societ}- contain materials for the inquiry, and for the
statistical, systematising study of physicians, fuller, far fuller
of promise for the good of mankind than pathology itself.

There will always, I presume, be a higher degree of cer-
tainty, what those things are which entering into the body pro-
duce diseases, than either how they produce them, or what the

JJ66 CLINICAL MEDICINE. [LECT. XXiX.

diseases themselves arc when they ai'c produced. Finding in
particular classes of men predominant modes of living and pre-
dominant diseases, and finding the same diseases follow the same
modes of living in individuals of all classes, Ave are more sure
that the modes of living produce the diseases, than we probably
«ver shall, or ever can be, how they do so. AVe are more sure
that the habitual and intemperate use of spirits leads to exten-
sively difiused deposits of cartilage and atheroma and bone
within the arteries, to haemorrhages from mucous surfaces, to
thickening and opacity of serous membranes, to cellular efi'u-
sions, to granidated kidneys, and to augmented bulk and capa-
city of the heart, and to a poisoned and corrupted blood ; we
are more sure, I sa}^ of the outicanl cause, than we ever shall
or can be of the inward root, germination, and growth, or of the
natural order and sequence of these diseases, by which mankind
suffer and perish hopelessly and inevitably.

Our surer knowledge, which regards external causes, is most
within our reach. Its fruit is most appreciable and at hand.
It concerns the prevention of what is often incurable. It claims
:an industrious pursuit under a moral obligation, if not from
its scientific character. But our more precarious knowledge,
which regards internal operations, is what we are most proud
of. We learn and we unlearn, and win a truth after the labour
of years, and cannot lielp putting a high price upon it. And
indeed it has a scientific value which I will not venture to
dispute or to depreciate.

LECT. XXX. J TIJEATMKNT OF VAI.VIILAK* DLSKASK. 367

LECTURE XXX.

IKKATMENT OF UNSOUNDNESS OF THE IIEART IN SOME OF ITS

rRINCIPAL FORMS. TREAT31ENT OF VALVUEAR UNSOUNDNESS.

IN VAEVULAR UNSOUNDNESS THE EXrECTATION OF MEDICINE

IS NOT TO CURE IT «UT TO STOP ITS INCREASE, OR TO POSTPONE

ITS CONSEQUENCES. THE NATURE OF THE DISEASE IN WHICH

THE VALVULAR UNSOUNDNESS ORIGINATED LIMITS OR ENLARGES

THE EXPECTATION. ALSO THE AG]', .\ND fONSTiriTION OF

INDIVIDUAL PATIENTS. CASES.

Having now passed in review the several forms of the heart's
nnsoimdness, whether they proceed simply from disease, or
simply from disorganisation, or are a complex of both, and
having considered their clinical diagnosis, and their clinical
lii story with the conditions prior, preparatory, and conducive
to them, whether in the heart or beyond the heart, in the body
■or without the body, we come better prepared for enquiring
into their treatment. We may perhaps already calculate, from
the nature of things, the probable expectation of remedies
addressed to them ; but we must see also v.hat from experience
are their actual effects.

Valvular disease of the heart, as far as I at present either'
know or believe, can only be contemplated in reference to its
•cure, when it is a part of endocarditis, and is of the nature of
inflammation. Of its treatment as such enough has been said
already.

That valvular unsoundness which remains after the subsi-
dence of inflammation, and that which is the result of slow and
covert disease, may not be beyond the reach of medical treat-
ment for every purpose, but beyond its reach it certainly is for
the purpose of cure.

What medical treatment can do, and what pur]3ose it can
answer in such forms of disease, now comes to be considered.

Where the valvular unsoujidness is small, and hitherto

368 CLINICAL MEDICINE. [lECT. XXX,

little or not at all complicated with other disease of the heart,
medical treatment has sometimes succeeded in withholding it
from hccoinhifj (j reciter. It has restricted it to what it is, and at
the same time prevented or greatly postponed those further
structural changes in the same organ which are naturally liable
to follow.

Valvular unsoundness may exist, and there be no extra-
ordinary impulse of the heart within the chest, no habitual dis-
turbance of the circulation, no jerking of the arteries, na
congestion of the veins, no hindrance of growth or nutrition to
the body at large, no impediment of any function which it
belongs to blood or blood-vessels to perform, and no conscious-
ness on the part of the patient, under any circumstances, of the
least drawback upon the powers and capacities of health. The
fact of the unsoundness is a secret known only to the phj^sician ;
and the single sign denoting it is a loud endocardial murmur.

Or valvular unsoundness may exist, and there be perfect
health to our observation in every thing besides, yet to the
patient's own feeling a certain amount of conscious drawback-
He may have learnt, that there is a degree of bodily exertion
which he cannot reach without some painful hurry of breathing-
and some palpitation of heart. But if he were always careful
to keep witliin that degree, he would never know that he was ilL

The most frequent specimens of valvular unsoundness,
existing under these conditions, are found in those Avho at
some past period of their lives have suffered an attack of acute
rheumatism in which the heart Avas affected. And then a great
deal is within the reach of prudent management for averting
further evil.

The first aim of the physician in such cases should alwaj^s-
be to make the patient clearly to vmderstand what his state is,^
and to see the reasonableness of the advice that is given him.
For his treatment, though it may proceed upon our suggestion,
must be entirely carried on by himself. It must engage every
hour of his life, and bo allowed to interfere with all his habits^
and conduct, ajid objects. A man, therefore, had need be well
persuaded, that what we require him to do is right, Avhen the
doino- it calls for so larffe an amount of self-sacrifice.

And indeed there are cases in which experience allows us
to hope sanguinely, and to promise largely upon the faith of

LECT. XXX.] TREATMENT OF VAI.VFJLAR DISEASE. 369

good resolutions, and fair obedience on the part of our patient.
For, though he have immoveahly fixed within his heart the
element of fatal disease, yet upon the condition of strict and
habitual temperance, and habitual self-control over body and
mind, (no easy condition I allow,) ho may count upon living
long and not unhappily, and upon postponing to a distant
period the evils which threaten his state, or even upon escaping
them altogether.

Now there is in these cases a special and peculiar ground of
hope ; and it is well that we should see and clearly understand
what it is. The small amount of valvular injury, and the
probability that the heart has hitherto undergone little or no
change of structure besides, and the present unembarrassed
state of the general circulation, are all favourable conditions.
Yet the special ground of hope does not rest here, but upon the
fact that the valvular injury had its origin in a certain casual
attack of inflammation. The valvular injury from this cause,
though it be incurable, does not increase but remains (there is
reason to believe) of the same exact amount, be it more or less,
at which it was left when the inflammation finally ceased. If
it be small, it remains small, and the evil consequences to which
it naturally tends, such as dilatation and hj^pertrophy, are slow
to emerge. If it be large, it remains large, but does not become
larger, and its evil consequences emerge more rapidly.

But the amount of valvular unsoundness left by acute
rheumatism is not always small. It may be very large. And
this is the chief cause of the widely different periods to which
men are found to survive the damage thus done to the heart.
The valvular unsoundness, according as it is small or great,
considered as the germ of future evil, takes a longer or a shorter
time to develope its consequences and to bring them to their
fatal maturity. Be it, however, small or great, if its evil con-
sequences have not yet arisen, there is always a better chance
of postponing them in these, than in other cases where there is
the same amount of valvular unsoundness from other causes.
That such is the matter of fact I am sure from experience ; and,
that the reason of the thing is as I have stated, I am pretty
confident.

Let us then now turn to the cases of valvular unsoundness
from other causes, and consider their treatment with reference

24

370 CLINICAL MEDICINE. [lECT. XXX.

to its only possible aim, viz. the postponement of evil conse-
quences which are yet to come.

There are cases in which auscultation finds a loud endocardial
murmur constantly present, denoting an injury of the aortic or
the mitral valve. And this is all we are sure of. There may
be, besides, some slight hypertrophy, or some slight dilatation.
But at all events the more formidable consequences of vahtilar-
injury are not yet apparent, and now is the time and opportu-
nity for their postponement, if indeed they can be postponed.
Accordingly we lay down strict injunctions for the patient's
habitual management of himself. And this is all we can do.
But we do it with little hope of putting off to any distant
period the fatal evils to which the valvular injury naturally
tends. But why not with the same hope in these as in the-
former cases? Because in these the origin of the valvulai*
injury cannot be traced back to any certain time, or to any
known attack of inflammation, but it has arisen from slow,
covert, and imperceptible disease. And, having arisen thus^
experience forbids us to reckon upon any long delay of its worst
results. And the reason of the thing tells us why.

There are diseases which are covert and imperceptible in
their beginnings, and still covert and imperceptible in their
progress, until at length they have wrought some palpable dis-
organisation of parts, and thus make discovery of their exist-
ence. By the time however they reach this point, the constitu-
tion adopts them as a part of itself, and so they can never after-
wards cease, but must go on still covertly and imperceptibly
augmenting their effects.

Disease of the endocardium is often of this kind. We first
know of its existence by the valvular injury which it has already
produced. The valvular injury may yet be small, but the disease
which produced it is still in progress and still going on to
augment it. Our aim is not its cure, but the postponement of
its evil consequences. Yet do what we will, we can expect little
success, while the original disease is ever at work, and the
original unsoundness is ever on the increase.

Further, such disease is seldom restricted to the heart. It
is almost always simidtaneously going on within the arteries.
Hence the injury, which it has already done to the one, is a
strong presumption of the like injury done or doing in the other..

LECT. XXX.] TREATMENT OF VALVULAR DISEASE. 371

If, therefore, the valvular unsoundness taken alono be little
likely to have its evil consequences postponed, much less likely
is this postponement wlicn the valvular unsoundness is combined
with dejiositions of various morbid products largely throughout
the arteries.

It appears, then, that valvular unsoundness, itself absolutely
incurable, is apt to admit of long postponement, and delay of the
evil and fatal consequences to which it tends, when it is in its
own nature stationary and unincreasing. And we judge it most
likely to bo stationary and unincreasing, if its origin can be
distinctly traced to some known period and to some certain
attack of accidental disease. On the other hand it appears, that
valvular imsoundness is apt to admit no such postponement of
its consequences, when it is in its own nature progressive. And
we judge it most likely to be progressive, if it be the tardy
growth of covert and imperceptible disease.

But neither what we know of the pathology of valvular
diseases, nor what we know of their clinical history, will allow
us to set up absolute rules of judging Avhat will be their conse-
quences and events in all cases, or how far they can or cannot
be postponed.

I have known a few cases in which the fact of detriment
done to a valve of the heart has been unquestionable ; and I
should have expected, from circumstances, a very dilfercnt event
from what actually happened. Their clinical history has not
been marked by any known attack of accidental disease which
could have come and gone, and injured a valve and left it un-
repaired. But the valvular unsoundness has taken place covertly
and imperceptibly, and there has seemed to be no reason wh)^
the hidden disease, which first formed it, should not still exist
and go on continually to augment it. But for years and years
it has remained apparently without increase in itself, and cer-
tainly without addition of any formidable consequence ; and for
years and years it has remained harmless, or nearly harmless,
and the patients have been entirely unconscious of ailment, or
sensible only of some hurry of circulation upon occasions of
unusual excitement.

But, besides the circumstances which have been mentioned,
there are others belonging to the age and constitution of indi-
Tidual patients, that would reasonably incline us to conjee turo

372 CLINICAL MEDICINE. [leCT. XXX.

differently of the disease wliich caused the valvular injury, and
to look for different results ; to hope in one case that the post-
ponement of its evil consequences was possible, and to fear in
another case that it was not.

Youth and the aspect of health, and the known habits and
enjoyment of health, and the known exemption from hereditary
malady would encourage the hope that the disease, (or whatever
it was,) which caused the injury, though we knew neither its
nature nor the time of its occurrence, was accidental and had
already ceased ; and that it never extended beyond the compass
of its still remaining effect in the valve of the heart. Here
we hope indeed more than we know. But this is a rational
hope.

On the other hand, advanced life and a cachectic aspect, and
the known habits and ailments of intemperance, or some bad
hereditary disposition strongly marked, or frequent attacks of
some constitutional disorder, such as gout, or rheumatism, or
gravel, would hardly suffer us to hope that the disease was
single and solitary in the mere valve of the heart which it had
injured, (though auscultation did not testify to more,) but would
rather lead us to fear its imiversality in the whole arterial
system. Here indeed we fear more than we know. But this
is a rational fear.

I know two young ladles, whom, when I first saw them, one
twelve years ago, and the other nine, I did not expect to be alive,
and, but for one infirmity, both in perfect health at this day.
I was called to see each of them on account of a loud systolic
endocardial murmur, which had been just found out accidentally.
In both it was audible throughout the prsecordial region and
far beyond it in front of the chest, and audible also extensively
through the arteries. No kind of illness had occurred in either
■of them to which it could be reasonably imputed.

"When the affection of the heart was first discovered, one
was a child only four years old. She has now passed her child-
hood and reached her sixteenth year. In the meantime she has
suffered several severe attacks of diffused bronchitis, also hoop-
ing cough and scarlatina anginosa. In the early stages of these
diseases the heart's action was most violent and almost tumul-
tuous, and active depletory remedies were employed.

During the last five years her health has been remarkably

LECT. XXX.] TREATMENT OF VALVULA.R DISEASE. 373

good. She is very active and fond of exercise. The heart's
impulse is easily excited ; but this appears to occasion her no
distress.

The other was in her tenth year, when the affection of the
heart was first discovered. She is now in her nineteenth. In
the mean time she has had scarlatina and measles. On these
occasions, and whenever her circulation has been excited by any
casual feverishness, she has suffered profuse bleeding from the
nose. She too, like the other, is brisk and lively. And the
impulse of the heart (I have observed) is raised by moderate
exertion; but she is unconscious that it is so.

And now, in one after the lapse of twelve years, and in the
other after the lapse of nine, auscultation finds the same condi-
tion of the heart which it found at first, and nothing more. In
the meanwhile, no treatment, properly medical, has been em-
ployed for either. Both have been the objects of prudent care,
but not of irksome restraint.

But who can tell the exact nature of the heart's affection in
these two cases ? Without doubt there is a valvular imperfec-
tion in both. But disease may have had nothing to do with
producing it in either. It may be a congenital imperfection.
The single sign denoting it was indeed found out at a certain
time by mere accident. But no one knows how much sooner it
might have been found out, had it been sooner sought for. At
all events this valvular imperfection, however produced, has
been stationary for years and been causing all the while some
amount of impediment to the current of blood, but no graver
consequences to the heart itself and to the constitution at large
have, after the lapse of many years, hitherto resulted.

These cases are full of interesting facts. — Here is a valvular
imperfection or injury. It has existed from birth or from very
early life. It still exists after many years. All along it has
been endured by the heart without any notable change or
detriment of its structure, without any painfid drawback upon
the health, the strength, or the comforts of life ; and on the
same easy terms it is still endured.

Do not these facts give intimation of a certain protective
power possibly inherent in the groiving heart, whereby it can
accommodate its form and manner of increase to material acci-
dents and so redress or counteract their evil tendencies ?

374 CLINICAL MEDICINE. [lECT. XXX.

I^ow it takes the experience of a vast number of cases to
make a man wise enough to pronounce confidently upon the
issue of any form of disease. And experience is a thing which
we must wait for ; we cannot make it for ourselves.

Indeed some forms of disease are so rare, that if all the
experience of them which there is in the world were put
together and possessed by one man, it would not make him very
wise upon the matter.

Physicians however are in a manner often called upon to be
wiser than they possibly can be. Disease or imperfection of a
vital organ is a fearfully interesting thing to him who suffers
it, and he presses to learn all that is known, and often much
more than is known about it. He is especially solicitous to
know what will be the result. Thus urged, we sometimes find
ourselves giving opinions and prognostics, where our experience
would hardly justify us in giving a guess.

What will be the end of the two interesting cases which have
been related, I cannot take upon myself to pronounce. For I
have no experience of other like cases to guide me. And yet
the experience of these cases themselves hitherto seems to con-
tain something of earnest and warning as to the future, some-
thing of promise, and something of fear and every thing of
practical caution.

That a certain degree of hindrance to the current of blood
through the heart should have existed, in one case for nine and
in the other for twelve years, without inducing further change
of structure in the organ itself, or doing serious detriment to
various important functions throughout the body, must en-
courage the hope that these great evils still admit of long post-
ponement. And the same hope must be strengthened by all we
know of the wonderful power of adaptation possessed by the
body, during its growth and adolescence, a power, by which it
contrives the means of bearing itself harmless and of conserving
life. But on the other hand the little it takes in both these
cases to rouse the heart to excess of impulse, and the readiness
with which inflammation in one, and haemorrhage in the other,
are apt to break out, taking occasion from accidental diseases,
are enough to denote that life is in some jeopardy. They
suggest the need of continual watchfulness for averting or

LECT. XXX.] TREATMENT OF VALVULAR DISEASE. 375

mitiguting- every disease or ailment or casualty, which through
the body or the mind can impart a hurtful and hazardous

• excitement to the circulation.

Let me add the sketch of another case which, as far as it
has gone, runs parallel with the two former. Here the valvular
injury may have only very recently taken place. At all events
it had only very recently been discovered.

A fine rough, robust, healthy-looking schoolboy, nine years

• old, was brought to me two years ago, and my attention
directed to an unnatural sound of the heart, which the medical
man of the family had accidentally found out about a month
before. It was a systolic endocardial murmur, extremely loud,
and audible in every part of the chest in front, round to the
left axilla, about the left scapula, and especially in the space
between it and the spinal column. The murmur was most
intense just opposite the sigmoid valves, whence it was propa-
gated along the ascending aorta, subclavian and carotid arteries.
The second sound of the heart was a loud snap. There was no
undue extent or degree of impulse from the heart, and no
undue amount of didness to percussion in the precordial
region. The boy laughed at the notion, that any thing was the
matter with him. He was illustrious among his schoolfellows
for gymnastic feats and all sorts of athletic sports. Climbing
•and swinging by one arm or one leg with his head downwards
were favourite pastimes of his to the very day on which I
saw him.

The parents of the boy, aware that something wrong had
befallen his heart, naturally enough wished to know much more
about it than I could tell them. I told them, however, what I
knew of such cases, and made my little experience go as far as
it would in the way of encouragement. I told them, in short,
of the two young ladies, in Avhom there had been found years
ago the same auscultatory sign, denoting the same sort of
affection of the heart as I believed to exist in their own boy,
yet who were alive and likely to live at the present day,
enjoying a high degree of. habitual health, while the affection
of the heart remained still the same. I made also my little
■experience go as far as it Avould in the way of advice how to
manage him. I warned them and the boy himself against such

376 CLINlCAIi MEDICINE. [lECT. XXX.

extravagant feats of strength as had been his custom, and
recommended that he should come down to something a good
deal more moderate in the nature of bodily exercise. And
above all I insisted upon great watchfulness whenever he should
be ill, especially whenever he should suffer any febrile attack.
For I recollected the proneness to inflammation and hsemor-
rhage in the other two cases.

LECT. XXXI.] TREATMENT OF HYPERTROPHY. STT

LECTURE XXXI.

TREATMENT OF HYPERTROPHY OF THE HEART. DOUIJTS WHETHER'

rr BE REALLY' CURABLE. — COUNTERFEIT HYPERTROPHY.

SUPPOSED CASES OF CURE PROBABLY REFER TO IT. TRUE

HYPERTROPHY'. ITS TREATMENT CONTEMPLATES SOMETHING

SHORT OF CURE. BLOOD-LETTING. LIMITS OF ITS USE.

SUCCESS AND FAILURE OF TREATMENT. CAUSES OF FAILURE

IN CASES APPARENTLY' FAYOURABLE.

By most writers upon diseases of the heart I find its hyper-
trophy spoken of as curable. Its muscular substance having
acquired even a large increase of bulk is considered capable of
beinsr a sain brought down to its normal size and normal force
of action by medical treatment. And of the remedies con-
tributing to this result I find venacsection represented as the
chief. Now it would be unfair to mankind to abridge the hopes
and efforts of medical men in all things possible for their
benefit ; and the cure of hypertrophy of the heart does not
look like a thing which is in its nature impossible. But I
must confess that, in the whole course of my experience, I
never yet met with a single instance in which I was perfectly
satisfied that it was cured. This negative experience of mine
may not be worth much. Yet I have been a good deal in the
way of such things ; and it does appear rather strange that
what others have seen so often I should never have seen at all.
Therefore I may be pardoned for suspecting that physicians
affirming, not the mere curability of hypertrophy, but its very
frequent cure, Avere under some mistake.

At all events, this is one of the things which yet waits for
proof from recorded cases. A late eminent writer* has stated
that he had cases which afibrded him "reason to believe that
nearly the whole, who are under the age of forty, may be
radically cured, provided the hypertrophy is exempt from com-
* Hope, 289.

:378 CLINICAL MEDICINE. [lECT. XXXI.

plication with valvular or aortic disease, adhesion of the peri-
^cardium, softening of the heart or other organic obstacles to
the circulation ; and provided also that the constitution is
sound and the general health tolerably good." But he has
given no single specimen of his cases and was content with
this general allusion to them,

I am well aware that there is a mock hypertrophy of the
heart bearing so close a resemblance to the true that I should
find no fault with you for being taken in by the counterfeit.

There may be violent impulse of the heart, felt not only in
the praicordial region but in every part of the front of the
■chest upon which you lay your hand ; and there may be pain
in the heart, and pain and throbbing in the head ; and all
these may be never absent and often aggravated from time to
time by accidental circumstances ; and they may continue from
first to last for several months or for several years, and produce
in the mean while an incapacity of all useful exertion both
mental and bodily : all these may be, and yet there be no
hypertrophy.

Impulse of the heart, taken alone, however great and
however extensive it may be, is not a sure physical sign of
hypertrophy. Hypertrophy indeed cannot exist without excess
of impulse, but excess of impulse can exist without hyper-
trophy. When the impulse of the heart is excessive, and at
the same time its sounds are obtuse, muffled and indistinct, and
the praecordial region presents a larger space than natural
which is dull to percussion, then the signs of hypertrophy'' are
complete. And hypertrophy so sure and unquestionable was
never cured Avithin my experience. But when the impulse of
the heart is in excess, and at the same time its sounds are as
loud and clear as ever, or louder and clearer still, and the whole
pra}cordial region is quite resonant to percussion save the small
space which is naturally dull, then the signs of hypertrophy are
incomplete. Yet if this be enough to constitute hypertrophy,
I have seen and treated it successfully in a hundred instances.
But in the mean time I have not thought that I had to do with
any such affection or ever claimed the least credit for curing it.

Cases of mock hypertrophy of the heart are indeed very
numerous. Young persons at the prime of life are especially
•the subjects of it. They are often plethoric and often sedentary

LECT. XXXI.] TREATMENT OF IIYrERTROPHY. 379

and can assign the origin of tlieir complaint to no particular
time and to no particular exciting cause. In them the
excessive action of the heart is doubtless owing; to a rich and
redundant blood ; and the cure of their simulated hypertrophy
is eflPected by depiction and abstinence and the gradual
exchange of indolent for active habits. These are easy cases to
•deal with.

Again, young persons are the subjects of it, but they are
often pale and thin and dyspeptic and very sensitive, and
inactive from mere debility and nervousness. In them the
excessive action of the heart cannot be ascribed precisely to
any one thing. The stomach and the nerves and the blood
itself are all disordered, and they all are sources from which,
injurious influences ma}'^ spring up and travel to the beart ;
and they all have probably their share in producing the simu-
lated hypertrophy. Being so produced, its cure can only be
efi'ected by varied methods of treatment and after a long time,
and often not until the constitution has undergone some of
those changes which belong to stated periods of life. These
are by no means easy cases to deal with.

Again young persons are the subjects of it, but they are
often neither florid nor pale, neither too full nor too empty of
blood. They have no complaint that they can tell you of, and
none that you can make out, except an inordinate imj)ulse of
the heart ; an impulse great enough for any amount of hyper-
trophy, and constantly present, and admitting of severe aggra-
vation, and ever attended with pain, while the sounds of the
heart are still loud and clear, and the proscordial region is still
duly resonant.

These cases are the most difficult of all to deal with. Yet
their treatment seems theoretically to lie within a narrow com-
pass. There are no ailments of other organs to set right with
the hope that through them j^ou may reach the ailment of the
heart. The heart itself contains within itself the sole indicatioa
of its treatment. Abate its violent impulse and all will be well.
But bleeding will not abate it. Neither will all the variety of
anodynes and antispasmodics. Neither will digitalis. For
digitalis cannot be given long enough and largely enough for
any fair hope of it as a remedy, without fearful hazard of it as a
poison. In truth I know no certain medicine and no certain

380 CLINICAL MEDICINE. [lECT. XXXI.

plan of medical treatment ttat will abate this impulse. But
still I know that the very worst of these cases may get well. I
have seen some such and watched them for a time and then
have lost sight of them, and cannot tell how they have ended.
And some I have seen again after the lapse of years, and found
them as bad as ever : and some I have found perfectly well. In
these last cases then how has the cure been wrought ? Why,
it has not been wrought in the way, which would imply a
gradual process of bringing down an overgrown structure to its
natural size and dimensions. But it has been sudden and
abrupt, without any strict use of appropriate means, and some-
times with an utter neglect of them.

I remember a most painfully interesting case of this sort in
which a strong opinion was expressed by eminent physicians,,
that the heart was in a state of hypertrophy. With all humility
I held and expressed a contrary opinion. The patient was^
a young man for whom great interest had been used to-
get a commission in the navy. The commission was at last
obtained ; and he was ordered to join his ship by a certain
day. All his prospects in life were at stake. I fairly repre-
sented to his friends, that either he had a most formidable
disease, or he had nothing at all. The hazard was run. He-
joined his ship, sailed immediately for Greece and lost his pal-
pitation at the battle of Navarino.

But there is a treatment of real hypertrophy which now
comes to be considered ; a treatment not of cure but of mitiga-
tion and postponement, which has for its objects to make the
present evils of the disease as tolerable as may be and to avert
or to delay the still greater evils to which it naturally tends.

And bleedino; is among: the remedies, which we find our-
selves called upon frequently to employ for these purposes.
But the use of bleeding in hyj^ertrophy is an afiair of much
more caution and delicacy than you would suppose. I have a
general remark or two to make upon this point.

The forcible impidse of the heart and arteries, which charac-
terises hypertrophy, is far greater than that which ever attends
the most acute inflammation. Yet in hypertrophy the quantity
of blood which we are commonly content to take is small, and in
inflammation the quantity which we are often compelled to take
is large. In the case of inflammation the extraordinary impulse

LECT. XXXI.] TREATMENT OF HYPERTROPHY. 381

of the heart and arteries is the representative of new and extra-
ordinary actions in the whole living frame, and is itself a part
of them, of an universal strife of blood-vessels and nerves, of
fever and irritation, which are all engaged, in actuating, sus-
taining, and quickening the local disease. All these must be
brought down, before the inflammation can be made to cease ;
tind you can have no assurance that they are brought down
until you have effectually reduced the extraordinary impulse of
the heart and arteries. And a large loss of blood may be needed
for that purpose. And when it is needed, there is otherwise no
safety for the patient. But in the case of hypertrophy the
extraordinary impulse of the heart and arteries is no represen-
tative of present movements and irritations, febrile and nervous,
which are fatally at work in carrying on disease to a destruc-
tive event. It depends simply and exclusively upon a mere
mechanical force of extraordinary power acting upon the circu-
lation at its source. Therefore it would be in vain to think of
altering it by any amount of blood-letting, however large. For
the mechanical force, upon which it depends, is itself permanent
and unalterable.

But blood-letting is nevertheless a remedy for hypertrophy
of the heart. Yet, I repeat, cure is not its object, but the miti-
gation of present, and the postponement of coming evils. And so
it has no stated and constant use against abiding and essential and
unalterable symptoms, but an occasional use only agai nst inci-
dental emergencies as they arise ; such as pains and spasms of
the heart itself, dyspnoea, and coughs, and haemorrhages, and
vertigo, and torpor, and convulsions. It is for these, that bleed-
ing in some mode or measure is frequently needed . It may be
veneesection. And if so, to what amount? I really cannot
tell. Even, if the particular case was now before me, I coidd
not point to any indication which should guide you to take
more or less blood. The pulse, I have shown;£i8 no index at
all. Therefore I can only say, that the abstraction of a moderate
quantity usually answers every purpose of good, and that the
abstraction of a large quantity incurs great hazard of mischief.
If the incidental emergencies are capable at all of relief by vena3-
Bection, the relief will follow the loss of six or eight ounces at
most, and often of much less. Therefore let six or eight oimces
be the extreme quantity which is taken by way of experiment

382 CLINICAL MEDICINE. [leCT. XXXI.

in any case, with, whicli a^ou have no previous acquaintance. In
cases which you know, the measure of your bleeding to-day
must be governed by what has been well borne and has done-
good heretofore. Experience of the particular case is never so
much needed to enable you to do the right thing for incidental
emergencies, as in this chronic organic unsoundness of the heart.
The loss of a few ounces of blood from the arm, at intervals of
some weeks or months, may be the supreme remedy by which
you may meet all occasional emergencies, and may be the great
safeguard of the patient's life for years.

But vensesection at all may be more than is needed. It is so
in the majority of instances. Often, very often, have I seen,
after a few ounces of blood have been drawn from a vein, and
the praecordial anguish and dyspnoea and convulsive cough,
have been unmitigated in the smallest degree, that half a dozen
leeches have swept them all away at once.

It deserves to be mentioned indeed, as a thing beyond all
reasonable calculation, that a few leeches should be thus able
to overpower the most tumultuous conflict of pain and dyspnoea
and nervous alarm, which can be conceived. Yet they do eifect
all this so often and so completely, that I am accustomed to
resort to them, in these perilous emergencies of hypertrophy of
the heart, before any other method of taking blood. Unques-
tionably they succeed oftener in bringing relief than either
vensDsection or cupping.

In the long course of such an aifection as hypertrophy of
the heart, things to be feared, as well as things which actually
occur, have their due weight in determining us both what to do
and what to abstain from doing.

Now anscmia is an awful condition when it is added to hyper-
trophy of the heart, in whatever way it arises. And it may
arise in the natural course of things slowly and gradually, from
a defect or failure of the digestive and assimilative powers. Or
it may arise abruptly and suddenly from over-bleeding. And
no sooner does it take place, than the extreme evils of the
disease rush in upon the patient at once, and life runs rapidly
down to its close.

One might fancy, that in hypertrophy the very condition
of the circulation was such, as would enable it to bear with
impunity the withdrawal of the largest amount of its natural

LECT. XXXI.] TKEATMKNT OF IIYPEKTROIMIY. 383'

stimulus. One miglit fancy, tliat tlio heart's indomitable force
of action would prevent or mitigate the evils of an impoveriahed
and scanty blood. But it is not so. With the anaemia all the
cellular structure and every internal cavity have been filled
with serum in a few days. Or with tlie amcmia no serum has
been effused, but the heait has boat more forcibly than ever, and
the patient has been literally agonised and killed by the mere
violence of its impulse.

The palpitation which spring-s from antcmia, when the
heart is sound, how dreadful it sometimes is ! The pain, the
jar, and distraction of the brain seem too great to be borne.
Yet they commonly are borne, and they cease at last, and the
patient gets well. But much more dreadful is the palpitation
which springs from an;icmia, when the heart is in a state of
hypertrophy. Then the pain, the jar, and distraction of the-
brain are multiplied tenfold and are intolerable. Delirium
and convulsions arise, and death soon follows ; while neither
blood nor serum has escaj^ed from the blood-vessels, which
could be considered as the immediate cause of death.

Beware then, in the management of hj^pertrophy of the
heart, beware above all things, of bleeding your patients into
paleness and poverty of blood.

But in hypertrophy of the heart there are other methods of
compassing all possible ends within the reach of medical
treatment, besides venncsection and cupping and leeches. In
many a case no bleeding whatever has been employed from first
to last, and yet all the relief and mitigation, that could be fairly
expected, have been obtained. These other methods, however,
have their application to other forms of disorganisation and to
their pathological consequences, as well as to hypertrophy, and
therefore they will be more conveniently considered in another
place.

You might think perhaps that this hypertrophy of the heart,
which is independent of valvular injury, provided it have not
reached an extreme degree. Mould be a very manageable affec-
tion ; manageable (I mean) not as to its cure, but as to the
mitigation and postponement of evils belonging to it. Yet
what is the fact ? Wh}-, that the best treatment in cases, which
give (as far as we see) the fairest promise of success, is very apt.
to fail.

384 CLINICAL MEDICINE. [lECT. XXXI.

In some cases indeed no further evils arise, than such as
from necessity must be where hypertrophy exists. For years
there is still no mischief apparent except in the heart. And
this makes no progress. It spins upon itself and evolves
nothing beyond itself, neither dropsy nor haemorrhage nor any
^f those secondary diseases of lungs, or brain, or liver, which
are its looked- for consequences. — But these cases are the few.

In other cases, and these not the few, hypertrophy is hardly
known to exist, or is thought to be yet at its commencement,
when its ultimate evils begin prematurely to show themselves.
Dropsies, congestions and haemorrhages ; cerebral, pulmonary
and hepatic disorders arise and increase and admit of little miti-
gation, and death arrives far sooner than, regarding the heart as
the chief and sole centre of mischief, we should have thought
possible.

But after death dissection discloses the secret why our
remedies have failed, and why the ultimate evils (as they
seemed) of hypertrophy of the heart were so speedy to appear,
and so unmitigable and so rapidly fatal. In truth the dropsies,
the congestions, or the haemorrhages, or the diseases, functional
or structural, of brain, lungs, or liver were not, as they seemed,
the effects solely of the hypertrophied heart. But these and
the hypertrophied heart itself were secondary to something,
which preceded them all, and was the cause of them all, viz.
disease pervading the whole arterial system. The internal
lining of the arteries, to their third and fourth ramifications
and even their minuter branches is found puckered and
shrivelled and roughened with dej^osits of atheroma and carti-
lage and earthy matter.

By such disease their elasticity is destroyed, or their
natural calibre is altered ; and this is especially observable in
the aorta, which has sometimes undergone abrupt contractions
or large dilatations between its origin and its arch or some-
where in its course through the chest.

In the records of my early hospital practice I find nume-
rous instances, in which a moderate hypertrophy was the only
apparent cause of numerous accompanying conditions of
disease. And yet it seemed hardly capable of producing
them. But still this hypertrophy and these its supposed con-
sequences would admit of no mitigation and postponement.

LECT. XXXI.] TREATMENT OF HYPERTROPHY. 385

Death took place, and that was then disclosed, which in these
days would not escape detection during life, viz. granular
disease of the kidneys.

What exact relation such disease of the kidneys bears to
hypertrophy of the heart, we do not know even yet. But the
two are too often coincident in the same subjects for them
not to bear some, and that a very important, relation to each
other.

25

386 CLINICAL MEDICINE. fLECT. XXXII.

LECTUEE XXXII.

TREATMENT OF ATROPHY OF THE HEART — OF SOFTENING — OF
DILATATION. MEASURE OF ITC EXPECTED BENEFIT IN EACH.

Atrophy of the heart, or attenuation of its muscular substance,
is the form of disease which is naturally opposed to hyper-
trophy. Now of this atrophy, I doubt whether it can ever be
made a distinct object of medical treatment respective io cure.
I doubt whether the heart, having suffered such loss of sub-
stance from special disease of its own, can ever be made to
recover it again b}^ help of medicine.

When owing to defect of nourishment, from fever, or from
disease in particular organs, or from accident, the whole body
becomes weak and attenuated, the heart may perhaps (I am not
sure of the fact), share the general disorder and become weak
and attenuated also. And when the whole body, owing to
better nourishment, becomes robust and lusty again, the heart
may perhaps (I am not sure that it does) recover its natural
strength and substance.

But all this, although it may originally spring from disease,
yet, as far as the heart is concerned, has to do, not with disease,
but with degrees of health. The full energies of health
decline, and the heart suffers ; the full energies of health
revive and the heart is re-invigorated.

As to attenuation of the heart, when it is a special disease
of the organ itself, I cannot flatter myself that I ever cured it
even in its simplest form. The complex form in which it com-
monly appears may be safely pronounced incurable. The heart
which is attenuated is commonly softened, and the heart which
is attenuated and softened has commonly one, or both, of its
ventricles dilated.

Softening of the heart may be looked upon as reparable or
irreparable according to the conditions which have preceded it
and conduced to it, and which still accompany it.

LECT. XXXII.] TKEATMENT OF ATKOniY, SOFIEXING, KTC. 387

Wc will first consider it as a reparable disease.

There is a softening of the heart, which belongs to fevers
of a typhoid type, when the whole mass of blood becomes
loose and black and incoagulable, as if some foreign ingredient
or some new force had operated upon it so as to change its
chemical affinities and destroy for the time its natural properties
as blood. JN^ow this softening is reparable, though it is not
always repaired.

When in fevers the skin becomes dusky, and the impulse of
the heart fails and fails, until it can be felt no more ; and the
systolic sound of the heart fails and fails until it can be heard
no more ; and death follows, and after death the heart is found
to yield and fall in pieces under pressure of the fingers ; then
surely we cannot be wrong in ascribing to the softened heart a
large share in procuring the fatal result.

Again in fevers when the skin is dusky, and the impulse
and systolic sound of the heart both fail, and death is imminent
and threatening, and yet under the seasonable use of wine and.
stimulants the skin brightens and the heart is again felt and.
heard, and with its returning impulse and sound all inauspicious
symptoms are gradually cleared up and recovery is finally com-
plete, then surely we cannot bo wrong in believing, first that
the heart had been softened, and had afterwards recovered its
natural texture and power, and secondly, that this recovery of
its natural texture and power was mainl}^ instrumental in
saving life.

This softenino- of the heart in fevers is no new fact. But
the knowledge of the precise auscultatory signs which denote
its softening, and of the precise auscultatory signs which denote
its recovery, this indeed is new knowledge, and we owe it to
Dr. Stokes of Dublin. And further the detection, in these same
auscultatory signs of one precise and plain indication to guide us
in a mostdifficult point of medical practice, viz. the administration
of stimulants in fever, this too is new, and this too we owe to
the same sagacious physician. Whoever discovers a single new
indication of treatment, which shall prove just and true and
comprehensive, does a better service to mankind than if he
found out twenty new remedies.

From what I have seen I am convinced, that this softening
of the heart, by corruption of the blood in fevers, is often a very

388 CLINICAL MEDICINE. [lECT. XXXII.

rapid process and never a very slow one. And I am also con-
vinced that the recovery of the heart (when it does recover), by
restitution of the blood, is often a very rapid process and never
a very slow one. The blood is soon changed from its healthy
state, and soon changed back again to it. The process seems
more chemical than vital from its mere rapidity.

Now, as to treatment, it should seem that whatever had
power to restore its healthy quality to the blood would be the
remedy most suitable to recover the heart from its softened con-
dition ; and theoretically one would look to chemistry for it.
But chemistry has no such remedy to offer us; and so we are
left to make the best of our mere experience and to sustain the
nervous system and the movements of the heart by simple
stimulation, while nature transacts the business of reparation
in her own way. Our remedies have no other purpose, and
probably have no other effect, than to keep up a little life until
the blood is able spontaneously to restore itself, and by conse-
quence to restore the heart, and whatever other organs may
have suffered the like detriment with it, to the conditions of
health.

There is also a softening of the heart, which belongs to
certain diseases of a chronic kind characterised by an unhealthy
state of the blood ; such as scurvy and chlorotic anaemia.
When people die of scurvy the muscular structure of various
organs throughout the body is found loose and soddened and
without its natural cohesion, and of the heart among the rest.
And when they die of chlorotic anaemia, internal parts are not
only found as bloodless as the surface, but also loose of texture.
Such is the condition of muscles, and among the rest of the
heart.

But recovery is infinitely the more frequent event of these
diseases; even full and complete recovery, when it is impos-
sible to doubt that the heart and whatever other parts have
suffered detriment are restored to their natural integrity,

Now in these cases the softened heart has no special remedy.
Its treatment is merged in the treatment of the scurvy or the
anaemia. Cure the one by lemon juice and the other by steel,
and you cannot help but cure the softened heart.

Be it remembered, that the softening of the heart, which
belongs either to fever, or to scurvy, or to chlorotic anaemia, is

LECT. XXXII.] TKEATMENT OFATKOPIIY, SOFTENING, ETC. ,189

part only of a great constitutional disease, and that it partakes
of" the same nature and admits the same influences for good or
for evil, and the same means of cure.

This, then, is a sure fact of pathology, and very important
to know, that the heart, whether its softened state has been of
very short duration as in fevers, or of very long duration as
in scurvy and an-.cmia, is caj)able of regaining the original
firmness and consistence of its healthy structure, when the
fever or scurvy or ansomia is past.

But though this be possible in the nature of things, is it
commonly the actual event ? Indeed I believe it is. Yet it is
otherwise stated in books ; where the softening of the heart
begun in fevers is looked upon (I find) as likely ever afterwards
to remain and to terminate in the worst pathological con-
sequences. That this has happened, I must admit. For one
or two such cases have been reported to me upon authority
which I can entirely trust. But I have no record of any case
in my possession, and I have no remembrance of any, where a
chronic disease of the heart, which had softening for its main
characteristic, could be fairly traced back to a certain period,
when the patient sufiered fever.

So too the softening of the heart begun in scurvy and
ana3mia is spoken of (I find) as apt to be permanent and lead
to fatal results. Now I have no right to be absolutely incre-
dulous about the possibility of things which I have never seen.
Nor am I. Yet I may well doubt their frequent occurrence,
when, being both in the way of them and upon the look-out for
them, I have never yet met with them at all.

From what I have seen I suspect it to be an indispen-
sable condition to the possibility of cure in these cases that the
disease of the heart should be a simple softening of its muscular
structure and nothing more.

But we have now to consider the softening of the heart as
an irreparable disease. Yet as such it is still the same disease
anatomically, but another disease in all its pathological rela-
tions ; and hence it comes to be irreparable.

When it is a part of fever or of scurvy or of anaemia, its
treatment is merged in tlteir treatment, and it is reparable
because they are reparable.

In the majority of cases, however, softening of the heart is

390 CLINICAL MEDICINE. [lECT, XXXIL

not found coincident in its origin either witli these, or with
any other constitutional maladies of a like character, namely,
with such as have a stated course to run, or are spontaneously
curable, or curable by help of medicine. But it is secret in its
beginning and secret still in its stages and periods, until at last
we find it one among many diseases of other parts which have
been as covert in their origin and groAvth as itself. Of it and
of them it is now in vain to enquire which preceded and which
followed; and, looking upon them pathologically, we cannot
tell whether to reckon each as several or all as one disease.

The patients are in the decline of life, or they have fore-
stalled the season of old ago by intemperate habits. Their
nervous system may be shattered : their arteries may have
undergone extensive changes of structure : their livers may be
enlarged, their kidneys may be granulated. All of these forms
of disease may be, and some of them are sure to be, conjoined
with softening of the heart, before it comes to be known and
to be treated.

And, further, before it comes to be known and to be treated,
the softening of the heart is already a part only of a complex
disease in the organ itself. The very same tissue, the muscular
tissue, has undergone other disorganisation besides softening.
Either it is augmented in bulk and hypertrophied, or it is
diminished in bulk and attenuated. This chronic softening of
the heart is (as far as I know) always united either with
hypertrophy or attenuation.

Further, a heart softened and hypertrophied, or a heart
softened and attenuated, has (as far as I know) always one or
both of its ventricles dilated.

Thus this chronic softening is a part of a threefold dis-
organisation of the heart. And, if each part separately offers
(as it does) but a slender hope of cure, the complex of the
three may be set down as incurable. No bark or steel or tonic
remedy can now reach the henrt and strengthen it. No mer-
cury or iodine or alterative remedy can now reach the heart
and change it to its natural state again.

Is dilatation of the heart per se a reparable disease ? W^e
are encouraged to believe that it is upon good authority. But
I can really find no satisfactory evidence of the fact. I even
doubt whether there be any such thing as a dilatation of the

LECT.XXXII.] TREATMENT OF ATROPHY, SOFTENING, ETC. 391

heart, per se ; whether either ventricle ever have a comtuntly
enhirged capacity while its walls arc of a perfectly normal and
healthy structure.

jN^o doubt there is a temporary yielding of the ventricles in
obedience to a temporary necessity. This is seen especially on
the right side of the heart, when blood is detained within it
from obstruction to its passage througli the lungs ; but as soon
as the pulmonary circulation is set free, the heart, being no
longer surcharged with blood, returns upon itself and the
ventricle resumes its normal capacity. But this is distention,
not dilatation. And it is for the very purpose of enabling it
to bear this distention and to recover from it, that the heart is
endowed with its great physical property of elasticity.

Now I understand this to be the distinction between disten-
tion and dilatation. The capacity of the ventricle may be
indeed augmented equally in both ; but in the one the elastic
property of the heart remains, and is ready to bring back its
capacity to what it' was and what it ought to be, when the
extraordinary pressure from within shall cease ; while in the
other the elastic property is lost, and so the power is wanting
to bring back its capacity to what it was and what it ought
to be.

But how is this elastic property lost ? Is it not because the
muscular structure in which it resides .has lost its perfect
organisation ? When the heart is dilated, it is (I believe)
always at the same time either hypertrophied or attenuated or
softened. And it is dilated, because it is hypertrophied or
attenuated or softened.

Dilatation, then, can never in itself become the sole or
direct object of medical treatment, inasmuch as it has no
manner of existence except incidentally to certain conditions
of the solid structure which bounds the cavities of the heart.
You cannot reach it remedially but through them. You can
cure a dilatation of the heart only by first curing an hyper-
trophy, an attenuation, or a softening of heart. How far these
are curable we have already considered.

Thus I have taken several of the most important diseases
of the heart which pathology has described and distinguished
by names, and have endeavoured to estimate, under the
guidance of such experience as I possess, how far, either singly

392 CLINICAL MEDICINE. [lECT. XXXII.

or in their more accustomed combinations, they are amenable
to medical treatment. And the result is, that in my belief a
too flattering representation has been made by writers of what
medicine is able to efiect respective to their cure.

Physicians do well to follow in the track of the pathologist.
Our treatment of disease should strive to keep pace, if it can,
with our hioicledge of disease : but we must not be disappointed
when it cannot. In a hundred instances we must be content
to know what is wrong without being able to set it right.

But diseases should not be too hastily pronounced irremedi-
able. We have indeed much knowledge from experience, but
not a complete knowledge, of what is remediable and what is
not, in all cases.

Diseases are irremediable in two senses; either nature
wants the power, or we want the remedy. The essential work,
or operative process of reparation, belongs to nature. Medicine
only furnishes inducements or removes impediments. Failure
may be on the part of one or the other, or of both.

Now after a certain amount of detriment done to an organ
by disease, we are as sure from experience, that restoration to
its integrity of structure is impossible, employ what remedy we
will, as we are that an amputated limb will never grow again.

Again, there are diseases, in which we are sure on the one
hand that reparation is within the power of nature; yet we
are sure on the other that, without the seasonable aid of
medicine there will be no reparation in fact. Such are acute
inflammations.

Again, there are diseases, in which there is no settled
opinion among physicians either as to the power of nature to effect
their reparation or the power of medicine to further it. Such
are hypertrophy, and atrophy and softening and dilatation of the
heart. Nor ought this to excite surprise. The diseases them-
selves are of very difficult investigation, and so are all points,
both pathological and practical, connected with them. No
wonder then, that upon the great point of their curability
medical men, whose experience is equal, should come to
different conclusions according as their minds are wont to be
satisfied with greater or less degrees of evidence, or their
tempers are more or less sanguine, or their opinions apt to be
more or less indulgent to their wishes.

LECT. XXXII.] TREATMENT OP ATROPHY, SOFTENING, ETC. 393

But medicine contemplates other objects besides cure. It
aims still to postpone the progress of incurable disease and to
put off its evil consequences ; and, when they can be no longer
postponed, it seeks to render them more tolerable.

When the heart has become a spoiled organ, it is still a
vital organ. Unsound as it is, all parts of the body still draw
the pabulum of their life and their functions from it. But
their life and their functions partake henceforward of the
heart's imperfections.

There is a mischief done to the heart which cannot be
undone, and an unsound heart cannot be made to do the office
of a sound one. But the unsound heart with even its imperfect
office, being essential to life, must yet have our care to avert
from it all possible obstacles and hindrances, in order that it
may not entirely fail. But with this view other organs and
systems of organs demand our attention more than the heart
itself in its own proper seat. Medicine is called upon to give
aid and support to every feeble and failing function throughout
the body, and so to prolong a precarious existence by lightening
the burden of the heart. But this opens to us a new field of
enquiry.

394 CLINICAL MEDICINE. [lECT. XXXIII.

LECTURE XXXIII.

EFFECTS OF AN UNSOUND HEART UPON THE GENERAL VASCULAR
SYSTEM, ACCORDING TO ITS DIFFERENT FORMS OF UNSOUND-
NESS. EFFECTS UPON THE VEINS. EFFECTS UPON THE

ARTERIES.

Thus far in one sense tlie heart has been taken as the centre of
disease. The actuating causes having their origin elsewhere,
have been followed in their bent and tendency toicards the
heart, and the disease itself has been sought and found and
treated in the heart.

But now the heart is to be taken as the centre of disease in
another sense, namely as its point of departure. The move-
ment of the actuating causes is to be followed in an ojDposite
direction, proceeding from the heart instead of tending toivards
it, and the disease itseK is to be sought and found and treated
in other parts.

Intermediate between the heart and all structures . and
organs throughout the body, and carrying the pabulum of life
through a thousand channels, is the vascular system, carrying
life, and healthy life, as far as it depends upon the heart, when
the heart is sound, and still carrying life but unhealthy life,
when the heart is unsound.

From the unsound heart a fountain of evil is opened which
reaches to all parts, and actual disease may be idtimately in-
duced upon all. But the intermediate vascular system may be
expected to give tokens antecedently, in the way of preparation
of what is going to take place. What sort of prepai'ation this
is, which is carried on within the veins and arteries, for diseases
to be developed anywhere or everywhere, becomes an interesting
enquiry.

To begin with the veins. The plainest and most palpable
effects of an unsound heart upon the circulation in the veins
arc denoted by their distended and overloaded state ; and not by

LECT. XXXIII.] PULSATIONS IN VEINS. 39-5

tliclr distended and overloaded state only, but their visible pul-
sation and quivering. The first denotes an impediment to the
transmission of blood onwards, the latter denotes its regurgi-
tation backwards.

Simple distention of the veins is often visible in every part
of the body. Pulsation or quivering seldom reaches beyond
the jugulars ; but I have seen it extend as far as the large
superficial veins of the hands and feet. The jugular veins,
when their pulsation is constant and very evident, have gene-
rally undergone some change in their natural capacity. They
stand out fi'om the neck like large round cords, equal almost in
size to the little finger. When their motion is a mere quiver-
ing and is not constantly present, they do not always appear
larger than natural.

To come at the real origin of any symptom, it is necessary
to ascertain what is the simplest form of disease with which it
is apt to be associated. Now I had found the symptom in
question, viz. the distended and pulsating jugular vein, asso-
ciated with such various and complex forms of unsoundness in
the heart, that for a long time I had no notion to which of them
it expressly belonged ; I had observed it with hypertrophy and
attenuation, with dilatation of the various cavities, and with
stricture at the various orifices. At length I met with it, where
the right auricle and ventricle were dilated while every other
part of the organ preserved its natural structure and capacity.
This, as far as I know, is the simplest form of unsoundness of
the heart with which it is ever associated. This, therefore, I
must believe to be its real efficient cause. And from this it may
still derive its origin, even when it is found associated with
more complex disorganisation of the heart, of which dilatation
of the right auricle and ventricle forms only a part.

Now one effect of dilatation of the right auricle and ven-
tricle obviously must be, that the aperture of communication
between them should become wider, and that the valvular
apparatus, which naturally does no more than close it, should
now be rendered inadequate to the purpose. Hence, every
time the ventricle contracts, blood is impelled backwards as
well as forwards. And the veins near the heart easily admit
its reo-urgitation.

But still one has seen a pulsation, a temporary pulsation, at

396 CLINICAL MEDICINE. [lECT. XXXIII.

least, of the jugular veins, under circumstances where it could
not be supposed that the right side of the heart was otherwise
than sound of structure. In a severe paroxysm of asthma one
has seen it, and both have ceased together.

Yet how can there be even a temporary pulsation of the
jugular veins, implying the regurgitation of blood within them,
while the right side of the heart is sound and the tricuspid
valve is healthy and capable of fulfilling its supposed
functions ?

Subsequent experiment has, I believe, confirmed the im-
portant fact which was first pointed out by Mr. Hunter, viz.
that the valves on the right side of the heart do not, in their
healthy state, perform the ofiice of barriers to the regurgitation
of blood as perfectly as those on the left. If the pulmonary
arter}' be injected towards the heart, the semilunar valve does
not entirely prevent the injection from passing into the right
ventricle ; if the right ventricle be injected towards the auricle
the tricuspid valve does not altogether exclude it from the
vena cava and the jugular veins.*

Now upon reflection it must appear, that this natural
attribute (for such it is) of the valves on the right side of the
heart, whereby in truth they fall short of the perfection of
valves, not only serves to mitigate the urgency of disease, but
is an admirable provision coming into frequent exercise in
health, and absolutely required to prevent the gravest injuries
and even to guard the continuance of life itself.

The whole blood of the body must needs pass through the
lungs where it is liable to suffer impediments daily and hourly.
Perfect respiration is necessary to perfect freedom of the pul-
monary circulation. But to how many checks and hindrances is
the respiration obnoxious, among other causes, from great bodily
exertion, from efforts of voice, and from many mental emotions ?
And all such checks and hindrances are felt by the pulmonary
circulation according to their degree ; and then nature is
called upon to bring into play her own express provision for
withholding for a time from the lungs that portion of blood
which they cannot bear, and (if need be) for throwing it back
upon the veins. Unquestionably one part of this provision is
the apparatus at the entrance of the pulmonary artery and
* Hunter on the Vascular System, cap. vii.

LECT. XXXIII.] SAFETY VALVE ACTION IN HEART. 397

between the right ventricle and auricle. It is even its imper-
fection, considered as valves and compared in its office as such
with the apparatus holding the same relative situations on the
left side of the heart, but its admirable perfection in its own
office and use, which gives this wondrous aptitude to sustain,
correct and compensate the accidental checks and hindrances of
the pulmonary circulation.

If the valves on the right side of the heart were, like
those on the left, absolute and unyielding barriers to the return
of blood, we must die of every exertion or accident which could
impede the respiration even for a short time. If the blood must
be forced forwards instantly and constantly, column by column,
as it arrives at the heart, the blood-vessels of the lungs must
be instantly and constantly ready to receive it ; otherwise they
must suffer rupture, and let loose a flood within them producing
death by pulmonary apoplexy. But nature has been provident
in ffuardinof agrainst such fatal necessities. The vessels of the
lungs cannot indeed at all times receive the same quantity of
blood, for they are not at all times equally free. Hence a
provision was necessary and a provision was made, which, in
accommodation to their varying capacities, allows some portion
of the blood to linger in the right side of the heart, and, if
need be, to fall back into the veins, until the lungs recover
their ability to transmit the whole.

There is then an extraordinary mode of action, which the
right side of the heart in its liealthij state is capable of exer-
cising for the regurgitation of blood into the veins. And this
regurgitation may be enough to produce distention and visible
pulsation of those nearest the heart. But the pulsation of the
jugular veins so produced is merely temporary, and must be
carefully distinguished from that which is permanent. For it
is the permanent, which is the symptom of an unsound heart.
The heart, having its right cavities largely dilated, cannot help
producing permanently that distention and pulsation of the
jugular veins, which it produces temporarily only and by an
extraordinary mode of action in its state of health.

The same case in the course of its progress is sometimes
found to exemplify both of these conditions. A man is the
subject of asthma ; and in the severer paroxysms of his disorder
the jugular veins are observed to stand out and to pulsate, but,

398 ■ CLINICAL MEDICINE. [lECT. XXXIII.

as soon as the attack is over, they subside and resume their
natural state. Thus far the right side of the heart, its struc-
ture being unimpaired, admits the regurgitation of blood for
the relief of the lungs as long as it is needed and no longer.
In process of time his asthmatic paroxysms become more fre-
quent, and strange to say, in the intervals between them the
jugular veins do not subside and cease to pulsate. There may
indeed be some degree of constant dyspnoea; but the venous
distention and pulsation are greater than the apparent impedi-
ment to the passage of blood through the lungs can explain.
They are greater now that they have become permanent, than
ever they were during the severest asthmatic paroxysms. In
truth the heart has undergone that change of structure which
an asthmatic state of the lungs is calculated to produce. Its
right cavities are permanently dilated and have produced per-
manent distention and pulsation of the jugular veins, as a
natural and necessary consequence.

Further, in regard to this state of the jugular veins, it is
worthy of notice that it is apt to arise at different periods of
time in different cases, and that, taken as a symptom of an un-
sound heart, it is apt to bear not always the same relation to its
other symptoms. It often shows itself at an early period and
is prominent from first to last. • And again it often shows itself
late and is superadded to other unequivocal symptoms which
have already long existed. Herein it exhibits a striking cor-
respondence with the peculiar change of structure from which
it takes its origin. For dilatation of the right cavities is often
the heart's sole or principal form of disorganisation from first
to last ; and again it is often consequential to other forms of
disorganisation which preceded it.

Where distention and pulsation of the jugular veins have
been among the earliest symptoms, and have continued constant
and prominent to the end, it may be inferred that the dis-
organisation began on the right side of the heart. Where
they have been among the latter symptoms, it may be inferred
that the disorganisation began in some other part of the heart
and subsequently reached the right side. And the eventual
appearance of distention and pulsation in the veins may then
be taken to mark the period at which the right auricle and ven-
tricle became dilated.

LECT.XXXIIl] ARTERIAL CIRCULATION IN DISEASED IIEAllT 399

Thus, from conditions apparent in the largest and nearest
veins to the heart, we can measure the degrees of impediment
raised by the heart's unsoundness to its returning blood. And
experience has learnt to which form of unsoundness the greatest
impediment belongs.

But the veins nearest the heart are a part only of the entire
venous system, the larger channels into which smaller ones
without number empty themselves. The larger therefore can-
not be obstructed and the smaller remain free. And so it is
that when the jugular veins are full and pulsating, the whole
surface of the body becomes dusky and the lips and eyelids
livid and swollen.

Such is the influence of an unsound heart upon the circula-
tion of blood in the veins, and such is the particular form of
unsoundness, which makes itself especially felt in this part of
the vascular system.

Here, then, behold the preparation within the veins for
diseases afterwards to be developed anywhere or everywhere,
of what nature it is, and how it is carried on. Hence come
congestions, efiusions, haemorrhages, inflammations.

Let us now turn to the arteries.

The plainest and most palpable effects of an unsound heart
upon the circulation in the arteries are denoted by their exces-
sive, or by their defective, or by their irregular, impulse. Not
that each of these may not consist with the heart's perfect free-
dom from organic injury. The sound heart is subject to hurtful
influences out of itself ; and these influences it often feels and
obeys and resents as if the injury were all its own, sound as it
is. Its contractions may have much more or much less than
their natural force, or they may lose their natural rhythm ;
and so the pidse become very strong or very feeble, or very
irregular.

But then the strong or the feeble or the irregular pulse
need not be (experience tells us) of any formidable account, as
long as the heart is sound. It may come and go, or it may
continue long or continue always, and yet have no present or
prospective evils beyond itself naturally and necessarily belong-
ing to it. But with the excessive or defective or irregular
impulse of the arteries, when it proceeds from an abiding
unsoundness of the heart, it is far otherwise. Then it is always

400 CLINICAL MEDICINE. [lECT. XXXIII.

the prelude or accompaniment of some deeper and more vital
derangements of the entire arterial circulation.

It is needless here to stop and discuss the signs, which are
to determine when an abnormal motion of the arteries is derived
from unsoundness of the heart, and when it is not. The dia-
gnosis lies in a small compass and is seldom difficult. It turns
altogether upon auscultation, when we apply it to the heart,
finding something, or finding nothing, organically wrong there.
But something organically wrong being found, its nature and
its seat next require to be learnt, for the sake of better under-
standing how the derangements of the arterial circulation have
arisen out of it, and how they are kept up by it from day to
day, and to what they ultimately tend ; and all this for the sake
also of better understanding how they are to be treated.

Now as to its seat ; in order to make itself felt first and
especially in the arteries, the heart's unsoundness must be of
the left side. And as to its nature ; when the impulse of the
arteries is permanently greater than natural, it must proceed
from some form of unsoundness which gives the heart a real
excess of organic power ; and not only so, but which induces and
actuates it to be constantly using this excess of power which it
has. Such is hypertrophy of the left ventricle. And when the
impulse of the arteries is permanently less than natural, it must
proceed from some form of unsoundness which entails upon the
heart a real defect of organic power and constantly keeps down
its actions to this small measure of power which it possesses.
Such is softening and such is attenuation. And when the
impulse of the arteries is irregular, it must proceed either from
some form of unsoundness which entails upon the heart a
simple defect of organic power, or from some which raises a
mechanical impediment to the current of blood. It must
come either from softening or attenuation. Or it must come
from valvular injury.

These, I am well aware, are not axioms ; and I do not pre-
tend to affirm them as such. But they are facts so far generally
true, as to contain something of a principle, which may be of use
in our further consideration of the subject.

Well, then, an overstrong heart produces an overstrong
pulse, and a weak heart produces a weak pulse ; and a weak
heart or a heart mechanically obstructed produces an irregular

liEeT.XXXIIl] ARTERIAL CIRCI : LATK )N IN DISEASED HEART. 401

pulse. These tilings arc easily stated, and in themselves are
hardly worth dwcllin<^ upon. But the deeper and more vital
derangements of the arterial circulation, which accompany
them, are of chief concern to us as physicians.

While the left ventricle preserves its natural size and struc-
ture, it distributes its blood to all parts with a force and in a
quantity proportionate to their several needs. It holds a salu-
iaiy and independent dominion over all, and yet allows to the
-extreme blood-vessels of each part their independent uses and
tfunctions.

But the left ventricle in a state of hypertrophy impels its
blood to all parts with a force and in a quantity greater than
they can bear. It now becomes an overmatch for the cir-
'Cidation. It does not so much preside as tyrannise over
it. Its power is painfully present everywhere. It pushes the
globules farther into the extreme branches than they would
naturally reach, and so reddens surfaces which are naturally
pale ; and to parts, which are naturally red, as muscle, it
imparts a more conspicuous redness. It encroaches upon the
independent functions of the capillaries until finally it abolishes
them. Hence congestions and dropsies and hcBmorrhages, and
diseases, of whatever name and whatever part, which result
from repletion of the blood-vessels and effusion of their contents.
Again, the left ventricle in a state of attenuation or soften-
ing impels its blood to all parts with a less force and in a less
•quantity than they need. It can now hardly be said to preside
over the circulation. Hardly is its power sensibly present any-
where. The blood, which leaves it, seems to make its own way,
as it can, by an unequal and ill- sustained current throughout
the body. And so parts become pale and dusky and mottled
and cold for want of the due measure of blood within them or
for want of sufficient vital briskness in its course. Hence there
result diseases of the same name at least as those which come
from hypertrophy, though not entirely of the same nature.
Passive, instead of active, congestions and effusions ; passive
instead of active, haemorrhages and inflammations.

Again valvular injury, while it renders the pulse irregular,
delays and obstructs the course of the blood through the arteries
in various measures according to its degree. And then these
.delays and obstructions according to their degrees bring a greater

26

402 CLINICAL MEDICINE. [lECT. XXXIII.

and greater hindrance, until finally tliey put a stop and a stand
to all that blood and blood-vessels have to do with the func-
tions of particular organs. And thus the ultimate effects of
valvular injurj' are the same with those of hypertrophy, and
those of softening and attenuation ; viz. congestions and effu-
sions, haemorrhages and inflammations.

Here then is a sketch of what unsoundness of the left side-
of the heart, according to its several forms, is calculated to
bring upon the arterial circulation and, through it, upon the
constitution at large. And it is, I believe, a true sketch, as far
as it goes. For just as simple and as plain as it is here repre-
sented, is the matter sometimes found to be in practice. And it
is well to begin with what is simplest and plainest.

It is sometimes (I say) found to be so ; but neither always
nor very often ; nor, when it is so, is it found so to continue
very long. Therefore, if I were to leave the matter here,
unsoundness of the heart and its effects, immediate and remote,
would seem, from my representation, a much simpler and
plainer piece of pathology than it really is.

But in the first place, these several forms of unsoundness
belonging to the left side of the heart, need not occur singly
and separately. Nor do they ; neither hypertrophy alone, or
attenuation alone, or softening alone, or valvular injury alone,
as if one naturally excluded another. On the contrarj^, they
are almost all capable of entering into combinations with one
another, and are continually found together. Hypertrophy
indeed cannot co-exist with attenuation ; for the same thing
cannot at once be thick and thin. But hypertrophy is com-
patible with softening, and softening with attenuation, and
valvular injury is compatible with them all, and, accordingly,
as far as they are all compatible, so far they often co-exist. In
fact, they naturally grow up together, or they naturally induce
one another, and thus, except during the actual progress of acute
disease or the earliest stages of chronic, it is a rare thing to
find the unsoundness of the heart limited to one particular
structure or to one particular form.

But do not these strange mixtures of disease produce strange
mixtures of symptoms ? And are not the modes, in which
especially the arterial circulation is effected, so complicated as
to defy the possibility of reducing them to any definite order ?

LECT.XXXIIl] ARTERIAL CIRCULATION IN DISEASED HEART. 403

And is not an extreme difficulty thus thrown in the way of our
present purpose ; the purpose, namely, of gaining an insight
into the operations then at work throughout the body, which
are preparatory to diseases of fatal tendency yet to come ?

Now the results of experience carefully considered will
show, I think, that there is in fact less perplexity belonging to
the matter, than would at first sight appear.

Two forms of unsoundness, which are ^themselves different
in kind, may produce the same effect upon the circulation. And
when such forms are combined, there is found indeed a complex
disease of the heart : yet an effect upon the circulation proceeds
from both, altogether as simple and entirely of one kind as
when each form exists alone, only greater in degree.

Attenuation of the left ventricle is one form of unsoundness,
and softening of the left ventricle is another. Attenuation pro-
duces feebleness of the pulse, and softening does the same. And
when they occur together, their combination serves but to give
the pulse a greater feebleness and to bring on those deeper
derangements of the arterial circulation, which are common to
both, sooner, and to impress them with a more decided character.
Here then there are no discordant results to reconcile.
Two causes are found operating in the same direction ; and the
effect of one is simply multiplied by the effect of the other.

Again, there are several forms of unsoundness in the heart
which may be said rather to tend toicards a certain effect upon
the arterial circialation than necessarily to produce it. They
must reach a certain amount before the effect is sure to follow.
Yet where each separately would not be enough to produce it,
from their combination it would arise inevitably. Attenuation
of the left ventricle, softening of the left ventricle, injury of the
valves either at its entrance or its exit, all tend to interrupt its
rhythmical action and to make the pulse irregular. But the
heart does not lose its rhythm and the pulse its regularity from
every attenuation, or from every softening of the ventricle, or
from every injury of the mitral or aortic valve. The attenua-
tion or the softening or the valvular injury must be extreme
for either of them singly to produce this effect upon the heart
and arteries. But the combination of all three, though each
were but of small amount, would produce it inevitably.
Here, too, there are no discordant results to reconcile.

404 CLINICAL MEDICINE. [lECT. XXXIII.

In speaking of distinct forms of unsoundness in the heart,
and in endeavouring to appreciate their separate influence upon
the arterial circulation, we passed by all mention of dilatation
of the left ventricle.

The truth is, that experience hardly recognises it as a distinct
form of unsoundness, and can take no sure measure of the
separate influence which belongs to it. But there is no form
with which it is not found in alliance, and the part which it
then acts in combination, is not difiicult to interpret.

Whether the left ventricle gain or lose in muscular substance
or gain or lose in muscular consistence, it is apt at the same
time to acquire an augmentation of its capacity. Now when
this is the case, what efiect upon the circulation within the
arteries can be attributed to the dilatation beyond what would
result from the hypertrophy alone, or from the attenuation
alone or the softening alone, in the several cases? I believe
nothing difierent in hind but something difierent in degree,
whether of more or less. Dilatation further augments the im-
pulse of an hypertrophied heart, which is already excessive.
And dilatation further diminishes the impulse of an attenuated
or a softened heart, which is already defective.

When the impulse of the heart is thus augmented both in
proportion to its hypertrophy and in proportion to its dilatation,
and each is great in degree, results of one kind are indeed fear-
fully displayed. The hypertrophied heart, constantly receiving
a larger quantity of blood into a more capacious ventricle, con-
stantly feels a greater stimulus, and, being ever ready with full
power to answer it, it does answer it by a never-failing, even by
a terrible reaction. Throwing forth more blood and moving it
column by column with a stronger current, it fills and distends
the arteries even to the peril of rupture and overflow, and
hurries on all its fatal consequences to an earlier and surer
consummation.

Again, when the impulse of the heart is diminished both in
proportion to its attenuation or its softening, and in proportion
to its dilatation, and both are great in degree, results of another
kind follow, and bear a very marked and exaggerated charac-
ter. The attenuated or softened heart receiving a larger quan-
tity of blood into a more capacious ventricle may feel a greater
stimulus, but it certainly has not the power to answer it ; and
answer it it does not by any adequate reaction. It conveys not

LEC1\ XXXIII J ARTERIAL CIRCULATION IN DISEASED HEART. 405

more but less blood into the arteries. It cannot cast forth what
it contains. And what remains behind, remains to stagnate and
regurgitate, distending the heart and baffling its motions,
oppressing the lungs and baffling the respiration or bringing
their vital functions to a sudden stop.

But two forms of unsoundness in the heart, which are them-
selves different in kind, may produce different effects upon the
arterial circulation. And, when they co-exist in the same heart,
one would exj)ect to find partly one effect and partly another,
and that thus a complication of opposites would result, which
would be quite unintelligible. Yet this need not be the case.
One effect may be taken up by, and merged and lost, in the
other ; and, while the imsoundness of the heart is of two kinds,
it may be felt by the arterial circulation as if it were of one kind
and one only.

Hypertrophy of the left ventricle gives an extreme force,
and softening of the left ventricle an extreme feebleness, to the
pulse. But the hypertrophied structure may become softened,
and the two conditions of hypertrophy and softening afterwards
subsist together. Yet there is no mixture of the effects of each
upon the circulation. The extreme force, which belongs to the
one, gives place to the extreme feebleness which belongs to the
other ; and all the other deeper and more vital derangements of
the circulation will thenceforth change their character, and be
altogether as if no hypertrophy existed in the heart but soften-
ing alone.

When softening is thus superadded to hypertrophy, and
when the effects characteristic of the first supersede the effects
characteristic of the second, then the change which the patient
experiences is upon the whole greatly, very greatly for the
worse. The change of strength for weakness is always for the
worse. But the mixture of these two forms of unsoundness in
the heart does, I believe, seldom occur, and hardly ever, when
it does occur, is it clearly made out during the life of the patient.
Indeed how is it possible that it should, when an entire order of
symptoms, which should indicate one part of the complex affec-
tion, the hypertrophy, is utterly abolished ?

There is however a mixture of two forms of unsoundness in
the heart, which is very common. All physicians of hospitals
are familiar with it from having examples of it constantly under
their observation. It is the mixture of hypertrophy and

406 CLINICAL MEDICINE. [lECT. XXXIII.

valvular injury. Here the diagnostic signs of botk remain,
so that there can never be the least doubt of the existence
of either. The impulse within the chest, constantly augmented
in degree and in extent, denotes the hypertrojjhy. The endo-
cardial murmur, constantly present, denotes the injur}' of the
valves.

But, while the coincidence of the two is thus far without
•prejudice to the diagnostic signs of either, yet looking further
to the actions of the heart itself, to the movements of the blood
within the arteries, and to the deeper and more vital derange-
ments, which naturally belong to each when they exist sepa-
rately, we clearly discern the effects of the one wonderfully
merged and lost in the effects of the other, now that they exist
in combination ; we see the effects of valvular injury merged
and lost in those of hypertrophy.

To valvular injury naturally belong an irregular contraction
of the ventricle and an irregular pulse, and obstructions and
delays to the course of blood through the arteries in various
measures according to its degree. To hypertrophy naturally
belong an excessive force of contraction in the ventricle and an
excessive impulse communicated to the current of blood in the
arteries. And this force and impulse are naturally opposed to
all that is irregular and eccentric in the action of the heart and
arteries, and even counteractive of it, when it would otherwise
arise. Thus they are counteractive of their irregular action,
when it otherwise would arise from valvular injury.

Moreover this coincidence of hypertrophy of the left ventricle
and of an injured valve exhibits the most beautiful example, in
the whole range of pathology, of the checking, redressing, and
compensating powers which nature possesses and uses in further-
ance of the great ends of mitigating distress and of protracting
life, when some important structure is damaged beyond the
possibility of reparation.

In this coincidence there is nothing of accident ; all is of
design. The important structure, damaged beyond the possi-
bility of reparation, is the valve. The unsoundness of the valve
comes first, and then produces the hypertrophy, and produces
with it the redress of its own injuries. While the valvular
imsoundness is yet small, and still when it has become greater,
and even still when it has become very great, the heart is often
foimd from first to last maintaining its rhythm and the pulse its

LECT.XXXIIl] ARTERIAL CIRCULATION IN DISEASED HEART. 407

regularity. And no wonder. For it is accompanied at every
stag-e of its increase by a proportionally increasing power of the
ventricle.

A loud systolic endocardial murmur and an excessive im-
pulse of the heart and a larger space of pra^cordial dulness than
natural, these are the sure and authentic signs of an injured
valve and hypertrophy of the left ventricle. Yet often and
often are these found to co-exist, when the order and sequence
of the heart's contractions and the beats of the pulse are per-
fectly regular and rhythmical. And further, with this certain
evidence of an injured valve and of hypertrophy of the left
ventricle, not only will the heart and the pulse beat regularly,
but the blood will continue to be distributed freely and equably
throughout the body. Often the complexion is still healthy,
the lips florid and the body well nourished.

Here it is the hypertrophy, which is the safety of the patient
and enables life to go on as it does. Take away the hypertrophy
• and leave the injured valve, and the patient would be in a far
worse state than he now is : worse with half his disease than he
now is with the whole of it. The pulse would begin to flutter,
the complexion would become dusky and the lips blue, and the
surface of the body mottled and patched in consequence of the
blood being here and there imequally distributed or partially
■ detained. The ventricle reduced to its common bulk would
want the power needed to impel the blood steadily onwards
. against an extraordinary obstacle.

But let nothing that has been said be misinterpreted.
Hypertrophy of the left ventricle is still a tremendous evil.
Recollect its immediate efiects upon the arterial circulation,
which are preparatory to others more formidable and more fatal,
ready to be developed in due season. And valvular injury too
is still a tremendous evil. Recollect also its immediate and
ultimate efiects, which are alike formidable and fatal. True it
is, that in the coincidence of the two, one is found to fulfil a
salutary ofiice respective to the other. But this is only for a
time. The valvular injury and the mechanical impediment
annexed to it may increase beyond the possibility of deriving
relief from any compensating power whatever. And the hyper-
trophy too may so increase that the salutary ofiice, which might
belong to it in its lesser degree, is exchanged for an unmitigated
. and deadly mischief.

408 CLINICAL MEDICINE. [lECT. XXXSV^

LECTURE XXXIY.

GENERAI- VIEW OF THE SECO]S^DARY DISEASES WHICH PROCEED^

FROM AN ITKSOUND HEART, AND OF THEIR TREATMENT.

THEIR VAST PATHOLOGICAL RANGE. CONGESTIONS. EFFU-
SIONS,— h.f:morrhages. — inflammations. — inquiry into

THE COMMON PRINCIPLES OF THEIR CURABILITY. CURABLE

IN A HIGHER AND A LOWER SENSE ACCORDING TO THE

NATURE OF THEIR ACTUATING CAUSE. AS THE RESULT OF

AN UNSOUND HEART CURABLE ONLY IN A LOWER SENSE.

SUSPENSION. ABATEMENT. TEMPORARY REMOVAL POSSIBLE.

CONDITIONS LIMITING AND ENLARGING THE EXPECTATIONS

OF MEDICINE IN DIFFERENT CASES. FORM OF UNSOUNDNESS

IN THE HEART ITSELF. PRESENCE OH ABSENCE OF COINCI-
DENT DISEASE IN OTHER ORGANS. — THE NATURAL CONSTITU-
TION OF THE PATIENT, ^VHETIIER HEALTHY, OR PLETHORIC,

OR ANEMIC. THE PATIENT's CONDITION IN LIFE. THE TIME

AT WHICH TREATMENT IS FIRST INSTITUTED.

Congestion, effusion, hcemorrhage, inflammation are terms used
to express the elementary forms of disease Avhicli belong especi-
ally to blood and blood-vessels, and whicli, taken in all tbeir
bearings, comprise a very large portion of the entire domain of
pathology and j)ractice ; a portion Avbich has ever engaged the
study of the best minds, since medicine began to be cultivated
as a science.

What these forms of disease are essentially in themselves,
and how blood and blood-vessels are engaged in producing them,
also what are the preceding conditions which can be reasonably
thought to stand to them in the relation of causes, whether
predisposing or exciting, near or remote, within or without the
body ; upon all these important matters I must presume, that
some sound knowledge is already possessed. For I cannot now
enter upon them with a xiew to their explanation.

Only I woidd remark that, of the multitude of such matters-

LECT. XXXIV.] DISEASES SECONIUKV TO CARDIAC*. 409'

worth knowing-, there are some which are practically more-
desirable to bo known. It is especially desirable, with a view
to the best treatment of these diseases and with a view to the
best results to be expected from their treatment, that we should
be able, from among various preceding conditions, to choose
and fix upon those which possess the real force of actuating
causes in each particular case. For many causes may concur-
to produce one of them. Or a single cause may produce them
all, together or in turn. And that single cause may be an
unsound heart. Congestions and effusions and hiemorrhages-
and inflammations, in vaxj or every part of the body, may
be reckoned among the ultimate consequences of an imsoimd
heart. Now the fact of their having an unsound heart for
their actuating cause does not put them beyond the reach of
medical treatment. Very far from it. But it assigns certain
limits to what is to be expected from medicine. Our present
object is to inquire what those limits are.

But first a little thought may be well bestowed upon the
general subject of their curability under whatever circumstances
they occur. Every one knows with what uncertainty they are
found amenable to medicine, now easily, now scarcely, and now
not at all ; and it would be well, if we could, to come to some
right notion, what it is that makes them so.

Our remedies, or (to speak more to the purpose) our methods
of treatment for these aifections, are chosen according to the
objects we have in view. The atii'ections themselves and their
actuating causes may be both within our reach, and therefore
both within our view in treating them. And then we seek a
treatment which will compass both. We aim to get rid of
present disease and to leave nothing in the constitution from
which it can germinate afresh. This is cure in the highest
sense. Or only the afiections themselves may be within our
reach, and their actuating causes may be beyond it. And then
we seek a treatment which shall concern itself with the one,,
and stop short of all interference with the other. The best we
aim at is to get rid of present disease, while we leave the
patient just as likely to suffer it again at some future time, as
he was at first. This, if it may be called cure at all, is cure in
a much lower sense.

From malaria, from contagion, from absorbed poison, from

410 CLINICAL MEDICINE. [lECT. XXXIV.

heat and cold, from moist and dry, from bodily and mental
exhaustion comes fever, when all the blood-vessels suffer some
sort of disturbance and the whole blood some sort of corruption.
And from the blood-vessels thus suddenly disturbed and the
blood thus suddenly corrupted, as from their actuating causes,
may come rapid congestions or effusions or hajmorrhages or
inflammations. Here the actuating cause is so closely followed
by its result, that the two are almost coincident. Our treat-
ment hardly discriminates between them. It comprehends both
and seeks to counteract both simultaneously. And its success,
if it succeed, is speedy and complete. And its failure, if it
fail, is speedy and complete in like manner. Patients are
quickly rescued or they quickly die.

It is in the fevers of intertropical climates, that these
phenomena are most conspicuously disjolayed as well as the
power of medicine in controlling them.

Again, from too little food and defective nutrition, from too
much food and excessive nutrition, from noxious food and
vicious nutrition ; also from simple defectiveness of the diges-
tive and assimilative functions, arise a deteriorated blood and a
morbid action of the blood-vessels. And these, as actuating
causes, may bring about congestions, or effusions or haemor-
rhages or inflammations slowli/ and after the lapse of time.
Here the actuating cause has had long precedence of the result.
Our treatment easily discriminates between them. It com-
prehends both, but it ministers to each separately. And its
success and its failure are always lingering and wait to be
ratified by long trial. Patients are slow to recover and slow
to die.

Cases of disease are everywhere and every day occurring,
which, taken in their origin, their course, their character, their
events and in the conditions of their cure, and viewed compre-
hensively, are specimens of all that is here meant. For
diseases may bear diverse names according to the parts and
organs which they occupy, and still have a kindred nature and
acknowledge a common origin. Visceral fulness and enlarge-
ments, oedema of the extremities, bronchial defluxions, and diar-
rhoea, hffimatemesis and melaina, purpurcous spots and scorbutic
patches and various cutaneous eruptions, are so many specimens
of congestive, dropsical, haemorrhagic and inflammatory dis-

LECTT. XXXIV.] DISEASES SECONDARY TO CARDIAC. 411

ease. They arc to be directly ministered to and kept in check,
and cured, it may be, for the present, by their appropriate
remedies. And their kindred nature often makes Ihera
amenable to such remedies as have a similar mode of operation.
But this check or this cure, which they receive, is sure to be
temporary onl}^, unless the treatment be made moreover to
reach far back to preceding conditions which arc their actuating
•causes ; unless, by medicine and by regimen, which have an
alterative and tonic power, its healthy quality be restored to
the blood and their healthy action to the blood-vessels.

But again there are actuating causes, which are different in
their nature from all these and which yet have to do with
blood and blood-vessels and which produce the same rej^ults,
■even congestions and effusions and haemorrhages and inflamma-
tions. Some single attack of acute disease may, after it has
ceased, leave a damage behind it in the part it occupied, which
can never afterwards be rej^aired. Or some slow disease may
have long lain covert, and only at last give notice of its
■existence by an incurable mischief which it has done. Thus
alterations of form and substance, thus degenerate structures
and foreign growths arise in any and CA-ery part of the body.
And then the functions of the part, whatever it be, determines
the nature of the injury that results to the health of the indi-
vidual. If it be the heart, forthwith a disturbance is brought
upon the mechanical forces, which move the blood. The blood
being unduly accelerated or retarded, arrested or regurgitated,
gives occasion to congestions or effusions or haemorrhages or
inflammations.

Here then observe how, in the nature of things, a much
narrower sphere is left for the operation of medicine. Medicine
is still concerned with the same diseases. But all preceding
•conditions, which stand in the relation of actuating causes to
present results, are placed beyond its reach. With their results
and with them alone it is left to deal, as best it may.

These few general remarks upon so large a subject as the
treatment of the most important and most frequent forms of
disease, which proceed from blood and blood-vessels, will not (I
trust) be thought superfluous. I want to find the principle of
their curability when they are cured, that we may be able to
distinguish the cases which fall within it, from those which lie

412 CLINICAL MEDICINE. [lECT. XXXIV-

beyond it, and so may come better prepared to our present
subject of inquiry.

The principle of their curability then is this, that their
treatment should be able to include within its remedial power
and agency not themselves only but also their actuating causes.
Their suspension, their abatement, even their temporary removal
may be possible, although the actuating cause still remains.
But then they are ever ready to begin again. This therefore
IS no perfect cure. Perfect cure looks to the removal both
of themselves and of their actuating causes. It does not indeed
contemplate that, after their removal, they shall never return.
Eut it does contemj)late that, before they can begin again, their
actuating cause Avill have to begin again also.

Such is the principle of their curability in the Mcjhcst sense.
And if so, it is plain that the congestions, effusions, haemor-
rhages and inflammations, which spring from an unsound
heart can never fall within it. ' If such be their cure and nothing
less, cured they never can be perfectly.

jS'evertheless their suspension, their abatement and even
their temporary removal may be considered within the possible
reach of medicine. The fact of their having an unsound heart
for their actuating cause assigns these as the general limits of
what is to be expected from their treatment.

Their suspension, their abatement or their temporary re-
moval is the extreme of what is possible. But how much of
what is possible can be deemed probable in any particular case,
the circumstances of that case must teU.

There are many forms of unsoimdness belonging to the
heart. You know what they are; valvular injury, hyper-
trophy, attenuation, softening, dilatation. And though some-
of these may have the benefit of a doubt, whether they be
absolutely irremediable or not, yet by the time they have pro-
duced any of the secondary' diseases in question, they must
surely have gone too far to admit the possibility of a perfect
cure.

Now one might suppose that the mere incurability of the
unsound heart, whatever might be the form of its unsoundness,
would assign an exact limit to the influence of remedies upon
the secondary diseases, which spring from it, and that this-
limit would be the same in every case. But such is not the

LEGT. XXXIV.J DISEASES SECONDARY TO CAUDIAC. 413

fact. The Incurability of the unsound lieart only determines
these secondary diseases not to be curable in the highest sense.
What is likely to be the effect of medicine upon them short of
perfect cure, that the partkulav fonn of unsoundness is con-
cerned in deciding.

Simple hypertrophy of the heart allows a freer use of
medical means in dealing with its pathological consequences,
and permits a fairer hope of the fullest measure of relief which
is possible, whether it be of their suspension, of their abatement
or of their temporary removal, than does either its attenua-
tion or its softening. Where there is an increase of structural
■organic power, there are many remedies with which we can
interfere from time to time and for a long time together, to
put restraint upon the excess of action which naturally results
from it. But where there is loss of structural organic power,
the remedies are few, if any, by which we can make up for the
defect of action which naturally results from it. We can go
nearer to reduce a strong heart to the level of a weak one, than
we can to raise a weak heart to the level of a strong one. As
an ingredient of disease and an object of treatment strength
is always more manageable than weakness. And, as with the
heart itself so with its effects ; congestions and effusions and
haemorrhages and inflammations admit many more remedies,
and remedies of much more power and efficacy, when the pulse
is strong, steady, and rhythmical, than when it is feeble,
fluttering, and irregular.

Bvit there is more to be taken into account than the par-
ticular form of unsoundness belonging to the heart, when we
wish to measure the probable eftects of medicine upon these its
ultimate pathological consequences. And it is this ; that the
iinsoundness of the heart is apt to be complicated with organic
diseases of other parts, diseases equally capable with itself of
producing the same pathological results.

If I except those cases, in which the damage done to the
beart could be clearly traced back to some distinct attack of
accidental disease, such as rheumatic inflammation, my records
of dissections (and they have been pretty numerous) do not
supply me with a single instance of a person reputed to die of
disorganised heart and its consequences, in whom after death
other parts also were not found disorganised, such as the liver.

414 CLINICAL MEDICINE. [lECT. XXXIV.

the kidneys, serous and mucous membranes, and above all, and
more frequently than all the rest, the whole arterial system.
And the kind of disease in other parts has been such as could
have in no wise been derived from the heart ; but it must
have grown out of special morbid processes within themselves,
whether prior or subsequent to, or simultaneous with, the
disease of the heart.

"When, therefore, there is dropsy and with it an unsound
heart, you must not be too sure that the unsound heart has
been altogether instrumental in producing it. The heart may
have only had its share, and its share may have been a small
one. When there is dropsy and with it that particular form of
unsoundness in the heart, which allows the freest use of medi-
cine for its relief, simple hypertroj^hy, you must not be too sure
that it will be actually relieved ; for this hypertrophy is apt to
be combined with extensive disease of the arterial system.

But there is more than the unsoundness of the heart itself,,
however well ascertained in its form and character, and there is
more than the superadded unsoundness of other organs, either
known or suspected, to be looked to, when we are concerned
with the secondary diseases in question. The quality of the
very blood which the unsound heart is circulating, now
becomes a potent contingency, and may hasten or postpone,
may increase or extenuate, all the evils which flow from it ; and
may modify their treatment and hinder or aid the operation of
remedies for their relief.

The general mind of the profession is just now all alive in
quest of the elements of disease in the blood. A good deal is
in a hopeful way of investigation, and some little is already
made out. But let us beware of the common fault of phy-
sicians in all ages, and not make too much of our new know-
ledge and call upon it prematurely to explain every thing.
Thus much, however, we cannot help seeing plainly enough^
that the opposite states of plethora and anaemia have a vast
pathological import both in themselves and in relation to all
diseases, come from what source they may. They have it un-
questionably, and they display it in relation to those secondary
diseases which spring from an unsound heart.

Plethora belongs essentially to the blood, and results from
one of its elements, the globules, being in excess. Now think

LFXT. XXXIV.] DISEASES SECONDARY TO CJARDIAC. 415

of wluit plethora is in its effects ; liow it modifies tlic i'unctions
of health, how it directly conduces to certain kinds of diseases,
and liow it stamps a peculiar character upon all.

Think of g-reat habitual force of the heart's action and
great habitual fulness of the pulse; of blood carrying with it
its visible colour of blood much further into the capillaries than
natural ; of rapid digestion and rapid nutrition, great conscious-
ness of strength and vitality, and great muscular development..
Such is the health of the plethoric.

Think of frequent vertigo and ringing in the ears, and fre-
quent drowsiness ; of si^ontaneous congestions and spontaneous
haemorrhages and feverish heat on slight provocations. Such
are the proper ailments of the plethoric.

And think of every accidental injury and every accidental
disease, whatever part of the body it may befall, being apt to
put on the character of inflammation and to demand blood-
letting. Such is the peculiar character which they have in the
plethoric.

Now plethora, if it be indeed the thing it is here said to be,
calls for continual watching and management and discipline ta
preserve that health which is ever bordering upon disease.
And it is well when, without any conspiring circumstances
beyond itself, a bare plethora is withheld from being consum-
mated in congestion or effusion or haemorrhage or inflamma-
tion. But when the heart is unsound and perhaps the blood-
vessels too, and perhaps many a solid structure besides, plethora
means something much more formidable.

Take that form of imsoundness of the heart, which is in
itself the least incompatible with the continuance of life, and
which is the most easily withheld from becoming worse and
whose evil consequences are the most easily postponed, simple
hypertrophy of small degree. This simple hypertro2)hy, when
the blood which the heart circulates is plethoric blood,
becomes conditionally a worse disease. It is more sure to aug-
ment itself and more sure to hurrj'- on rapidly to its worst
events. The heart feels an intolerable stimulus and resents it
powerfully.

Take other forms of unsoundness, such as greatly diminish
the organic power of the heart, or such as put positive
mechanical obstacles in the way of the circulation, attenuation,.

4.16 CLINICAL MEDICINE. [lECT. XXXIV.

softening, great valvular injury. Then the plethoric blood,
instead of being a stimulus, becomes a burden to the heart ; a
burden which it can hardly bear and hardly move. Then all
the face, the neck, and the lips are purple with blood, and the
jugular veins stand out, and there is an agonising dyspnoea,
and we look for sudden death by cerebral or pulmonary conges-
"tion or haemorrhage.

Again, anfcmia belongs essentially to the blood, and results
from one of its elements, the globules, being in defect. Con-
sider what ana3mia is in its effects ; how it, like plethora,
modifies the functions of health but in a different way ; how it
-too conduces to certain kinds of diseases, and how it stamps a
peculiar character upon all.

Habitual feebleness and frequency and occasional irregu-
larity of the heart's action, habitual smallness of the pulse,
•^the blood failing to give its colour to the skin and to the visible
portions of the mucous surface ; slow and painful digestion,
defective nutrition, cold extremities, nervous depression, mental
irresolution, such are the ingredients which go to make up the
health of the ana3mic at best.

Throbbing in the head, and vertigo and ringing in the ears
as frequent as in the plethoric, and pain more frequent and
more acute ; also spontaneous haemorrhage as in the plethoric,
but now taking the shape of purpureous spots and blotches ;
and oedema of the ankles and feet, these are the proper ailments
of the anffimic.

Then every accidental form of injury and disease putting
on the character of weakness ; inflammation itself failing to
accomplish the proper work of inflammation for want of power,
and not bearing the remedies of inflammation, yet still con-
tinuing pertinaciously, and often refusing to be cured ; such is
the character they have in the anaemic.

Now ana)mia, bare anaemia, is a thing formidable enough in
itself. Without disease or injury of any solid structure what-
ever, the essential disorder of the blood alone may kill. It may
give occasion to passive efiusions, and to passive haemorrhages,
and to passive inflammation, which bring on death.

As in plethora, so in anajmia, each unsoundness of the heart
becomes conditionally a worse disease, but worse in a different
way. As in plethora so in anaemia each unsoundness tends

LEC'I'. XXXIV.] DISEASES SECONDARY TO CAKDIAC. 417

more rapidly to its evil consequences, but those consequences
are apt to emerge in a different manner. Passive effusions,
ha}morrhages, and inflammations are rather wont to appear
everywhere than in certain parts. Death seldom now arrives by
oppression of the brain or the lungs singly, but oftener by
oppression of many organs simultaneously.

But there is yet another consideration which should be taken
into account, when we are calculating the probability of such
success as is possible in treating the secondary diseases, which
spring from an \msound heart. What I am now going to
allude to has nothing to do with any intrinsic pathology. It
comes not from within the body, yet does it exercise a vast
influence upon all that is going on within. Neither is it age
or sex or temper or temperament. These things indeed have
their weight ; though we need not be over curious (as we some-
times are) in putting them in the balance. We may safely
trust common sense to take them and weigh them and allow for
them as it pleases. But the consideration I allude to is simply
this, whether the patient be bound or not, by the necessity of
his being, to live by the sweat of his brow.

One part of mankind can take care of their bodies all their
life long. They need never use them but for recreation.
Another part cannot take care of them for a single day.
They must be always using them and toiling with them and
living by them. Yet, as long as health lasts, they that can
live at ease, if they will, have no very sure advantage over
those that must labour, Avhether they will or not. But, when
disease comes, their advantage is plain enough ; especially, if
that disease affect a vital organ, and, most esjpecially, if it
affect the heart.

Whatever form of unsoundness belong to the heart, the
patient's own instinct is continually telling him that he must
be still. For want of this needful quiet the heart makes
quicker progress in all its changes of structure and quicker
accumulation of their disastrous consequences. It is sooner
hypertrophied, sooner attenuated, sooner dilated, and the dis-
turbed blood-vessels sooner betake themselves to congestions
and effusions and haemorrhages and inflammations. And then,
for want of the same needful quiet, the hopes of medical treat-
ment are often disappointed. Neither their suspension nor

27

418 CLINICAL MEDICINE. [lECT. XXXIV.

their abatement nor their temporarj'- removal can now be pro-
mised upon any calculation of what the mere state of the
disease would render probable. Hundreds of people die many-
years sooner than their mere disease would bring them to an
end. Their disease would still let them live, but their adverse
fortune kills them.

There remains yet one more important circumstance, ex-
trinsic though it be, which claims to be noticed. If ever time
and opportunity come in to turn the balance of success in
favour of medical treatment, it is when we are concerned with
the secondary diseases which proceed from an unsound heart.

A disease, which by its own nature is placed fairly within
the power of medicine, may by the loss of opportunity escape
far beyond it. This is most strikingly shown in acute disease
but it is most frequently shown in chronic. Acute disease is
never more severely felt than on its first access ; consequently
it is then, that it most importunes our aid and most commonly
obtains it. But if it do not then obtain it ; if from the un-
fortunate condition of the patient the opportunity then be lost,
all is lost.

Chronic disease, on the contrary, is often not felt at all in
its beginnings and often little felt in its further progress, and
only at last decidedly felt when its efiects have so accumulated
as to oppress and overbear the functions of particular organs.
And then, and often not till then, it first importunes the aid of
medicine, when the time is past for counteracting the actions
and sufferings which are the disease, and nothing is now left but
to render its effects more tolerable. Here the opportunity,
which may be lost by the covertness of the disease, should be
saved by the watchfulness of the physician.

But our concern at present is not with original and primary
diseases whether acute or chronic, not with diseases engendered
anew in a sound body, which nothing might lead us to expect ;
but with secondary diseases springing from an unsoundness
already known, which we are ever on the watch for. Detection
therefore is much easier, if the patient be within reach.

Here' however is the perplexity, every man, who has an
unsound heart, had need to be always under the eye of a phy-
sician ; and then we, knowing what to expect, should be likely
to discern its evil consequences on their first appearance and

LECT. XXXIV.] DISEASES SECONDARY TO CARDIAC. 419

institute our treatment at tlio time most i\ivourable to its success.
I3ut this can seldom be the case. Yet what a vast diiierenco
does it make, whether our treatment commence as soon as a
slio'ht crepitation is heard in a small portion of one lung-, or be
delayed until it has pervaded a largo portion of both, or until
one side of the chest is entirely dull to percussion. Or whether
it commence with the first noticeable oedema of the ankles, or
it tarry until serum be let loose into the entire cellular struc-
ture of the body and into the cavities of the chest and the
abdomen.

I would presume to note it for a predominant fault of
systematic writers, that they are apt to take it for granted, that
we are always called to treat diseases just at the right time.
This is not dealing fairly with us.

Finally, of all that has been stated this is the sum : —
1st. That the fact of congestions or effusions or haemor-
rhages or inflammations having their actuating cause in an
unsound heart prohibits the possibility of their cure in the
highcd sense, and limits the expectations of medicine to their
suspension, their abatement or their temporary removal.

2ndly. That the form of unsoundness in the heart furnishes
a, measure of calculation, how much medicine will probably be
able to effect in the individual case, whether it will go to
suspend or to abate or even so far as to abolish them for a
time.

3rdly. That the presence or absence of coincident disease in
other organs always modifies those expectations of relief by
medicine, which the mere form of unsoundness in the heart
itself would lead us to entertain.

4thly. That constitutional plethora and anaemia are grave
contingencies when they are found in coincidence with an
unsound heart, having an important bearing upon its conse-
quences and upon our modes of treating them and upon our
expectations of giving relief.

5thly. That, besides all these intrinsic conditions, the ex-
trinsic accident of what may be the patient's circumstances in
life throws a great weight into the balance for or against the
probability of relief. The man, who, having an unsound heart,
must traffic with his sinews, for his daily bread, has a poor
chance of benefit from medicine.

420 CLINICAL MEDICINE. [lECT. XXXIV.

6tlily. That treatment has never more need of being favoured
by opportunity than it has now.

Having thus formally stated the conditions intrinsic and
extrinsic, which, being coincident with an unsound heart, give
a character to its secondary diseases and place them more or less
within the reach of medical treatment, I shall venture to refer
to them hereafter, without further explanation, as I may have
occasion, when I come to speak expressly of these diseases and
their management.

LEOT. XXXV.] THE LUNGS IN HEART DISEASE. 421

LECTURE XXXV.

PARTICULAR VIEW OF THE SECONDARY DISEASES WHICH PROCEED
FROM AN UNSOUND HEART, NOT LIMITED TO ANY CERTAIN

PART OF THE BODY. THE LUNGS THEIR MOST FREQUENT

SEAT. THE LUNGS, THEREFORE, THE CHIEF SCOPE OF MEDICAL

TREATMENT. THEIR NATURE WITHIN THE LUNGS. — THEIR

MODE OF TREATMENT AND MEASURE OF CURABILITY GREATLY
INFLUENCED BY THE FORM OF UNSOUNDNESS WITHIN THE
HEART. SECONDARY DISEASES OF THE BRAIN. — OF THE LIVER.

When medicine is to be brougtit to operate upon the secondary
diseases proceeding from blood and blood-vessels, which are the
result of an unsound heart, we now understand what are the
limits of its possible success, and we understand too what are
the contingencies which may interpose to aid or to hinder our
treatment.

But, after all, enough remains in the power of medicine to
make us study the choice of its means and to keep a careful
watch upon the opportunities of using them. Possible suspen-
sion and abatement and removal, though it be but for a time,
are no small things, when they are spoken of diseases, which
hecome inevitably fatal by their continuance or their increase.

But where in the body are these formidable affections, the
results and concomitants of an unsound heart, apt to appear ?
Both within and without, both deep-seated and on the surface,
sometimes plain to be seen and sometimes to be searched after
before they are found. — Many a man having an unsound heart
has been killed before his time by an internal congestion or
^flfusion, which has gone undetected and unministered to.

Cases of the following kind are not unfamiliar to me. A
man has hypertrophy of the heart in a moderate degree with
some small amount of valvular injury or with none at all.
Hitherto he has been tolerably free from painful palpitation and
dyspnoea except under excitement or extraordinary exertion.

422 CLINICAL MEDICINE. [lECT. XXXV.

But suddenly lie is found gasping and struggling for breath
and expecting instant dissolution. What is this ; and what is
to be done ? Truly one might be excused for thinking of
angina pectoris or some spasm of the heart, and flying to
ammonia and a3ther and opium for relief. But putting my ear
upon the chest I have found a small crepitation difiused through
the half of one lung, or in the half of one lung I have been
imable to catch any audible murmur whatever either natural or
morbid. A single cupping upon the chest, just opposite the
portion of the lung that labours, has swept away the crepitation,
or has removed the dulness and brought back the respiratory
murmur ; and the patient has been restored in a day or
two to his ordinary state of comfort. Here in one instance
there has been sudden and extensive efliusion into the extreme
bronchial ramifications or vesicular structure of the lung, and
in another there has been sudden and extensive cong-estion.

Such cases as these are very striking. All that belongs to-
the disease and all that belongs to the remedy is so clear, so-
marked and unequivocal ; pulmonary congestion and effusion,
suddenly coming on and life brought into instant peril ; and
then, with the use of the proper remedy, congestion and efi\ision
suddenly gone and life restored to safety.

These are specimens of what is apt to occur in cases of
unsound heart ; full-sized and full-drawn indeed, yet withal
true specimens ; and so the fittest to learn by. The same
things in kind, but drawn in a less distinct and smaller
character, are seen every day.

The lungs in short are the most frequent seat of the con-
gestions and efiusions, haemorrhages and inflammations, which
are the results and concomitants of an unsound heart ; and the
lungs are the chief scope of medical treatment from time to-
time in many cases, and even the sole scope from first to last
in some cases, of unsound heart. For, besides the general
reasons, which, when the heart is unsound, render the lungs
obnoxious, in common with all parts of the body, to these
afiections and which are to be found in the obstructed state of
the circulation, there are moreover special reasons which render
them obnoxious to the same in a greater degree, and which are
to be found in the close relationship and mutual dependency of
function subsisting between these two organs.

LECT. XXXV.] THE LUNGS IN HEART DISEASE. 423

If we analyse carefully the numerous processes of wliicli
any complicated disease consists, it is remarkable how many of
them we shall find among the means and contrivances, to which
nature resorts for defending, for prolonging, and, it may be,
for rescuing the life of the individual ; and how many symp-
toms which, as involved in these processes, we call symptoms of
disease, we might rather regard as signs of the curative pur-
pose, which nature is striving to accomplish.

All this is less apjDarent in the primary morbid action of a
part and its direct symptoms. But it is both apparent and
manifestly true in the secondary morbid processes arising in
other parts and in the symptoms which designate them. Let
us take for example the secondary morbid processes going on
within the lungs, when the heart is unsound.

Natvire does, as it were, make use of the lungs as the
readiest and the nearest channel through which to relieve the
oppression of the heart. The area of every bronchus and its
ramifications afibrd altogether an immense extent of mucous,
surface ; and nature calls sometimes upon a part and sometimes
upon the whole of it to relieve the heart and the circulation in
their embarrassment ; and sometimes she requires an augmenta-
tion merely of its natural secretions and sometimes a separation
of pure blood.

It is remarkable for how long a time the lungs are often
patient of this extraordinary use, which nature makes of them,
without detriment to their structure. For, to whatever extent
the mucovis membrane may be afiected and in whichever way,
whether it separate mucus or blood, whether there be an ex-
pectoration of phlegm merely or htemoptysis, the air is often
found passing through every part of the lungs within reach
and cognisance of the ear ; and indicating by sounds here and
there and everywhere the. fluid it meets with as it passes, and
that it does not pass iminterruptedly.

Now this profuse mucous expectoration or haemoptysis is
capable of being suspended or abated or removed for a while.
The imsoundness of the heart, by the time these pulmonary
symptoms have arisen is commonly beyond the possibility of
cure. Yet the numberless miseries contingent upon it are not
beyond the possibility of great relief and mitigation, which we
shall best succeed in procuring, if we keep our minds attentive

424 CLINICAL MEDICINE. [lECT. XXXV.

to the processes whicli nature is carrying on within the lungs,
and to the symptoms which bespeak what they are. For they
are not only significant of the way in which nature is attempt-
ing her own relief, but significant also of the manner in which
we should attempt to succour her.

Thus for months and months together and even for years,
we may keep people alive and give them incalculable comfort
by aiding the lungs in the ofiice of relief, which they are
striving to perform, to an unsound heart. This is done by
drawing blood from, or by producing vesication or counter-
irritation on, the walls of the chest, just when and where and
to the extent that may be required. "We should endeavour to
make out from time to time, by careful auscultation, what parts
of the lungs chiefl}'- labour, where they chieBy crepitate or
where they are becoming dull, and to the surface of the chest
immediately opposite those parts apply our remedies. Thus by
taking a few ounces of blood by cupping or leeches, or by apply-
ing a blister or a mustard poultice on the right spot and at the
right time, we shall often obtain a degree of relief for our
patient, which nothing but experience could lead us to expect.
And we shall obtain the like relief in the same case again and
again, always provided we take the same care to choose the
right spot and the right time in the application of our remedies
to the walls of the chest. And what is the secret of our
success ? The secret (I believe) is this. We are aiding nature
in the very channels through which she is seeking to obtain
succour for herself. Therefore our remedies are the more
effectual.

It would be difficult to overrate the value, as guides to
practice, of the signs which declare themselves through the
medium of the lungs in every case of unsound heart. The
practice which they suggest not only aids the lungs in the
office of relief which they are performing to the heart, but it
protects the lungs themselves against the mischiefs which are
perpetually threatened to their own structure. For though the
lungs may not hitherto have sufiered disorganisation, yet nature
is urged by a hard necessity and is making of them (if I may
say so) a perilous use. Exorbitant secretion and haemorrhage
cannot be frequently demanded and frequently supplied from
the bronchi and their extreme ramifications, without danger of

LECT. XXXV.] THE LUNGS IN HEART DISEASE. 425

injury and disease to the whole lung. Such an event we may
ward off lor a time ; and, as long as we succeed in so doing, wc
preserve for our patient his best chance of life. But, in the
event, the lungs can hold out no longer, and undergo changes
of structure which more and more embarrass and finally abolish
their vital functions. Thus we have condensations and soften-
ing and apoplexy.

Such are the operations carried on by the blood-vessels
through the medium of the lungs when the heart is unsound ;
and such is the greatest amount of possible success which
medicine can reach in aiding them or restraining them and in
rendering them harmless. There is no more interesting field
of pathology and practice than this. And herein there is great
need of watchfulness, that what is going on between the heart
and the lungs should be well made out from time to time, and
that medicine which waits to be guided by our view of its
necessity, should be brought to bear seasonably upon its objects
as they arise.

But no degree of watchfulness, no degree of skill in the use
of remedies will obtain the greatest success in all cases or
procure a long continuance of life. For circumstances will
prevent it.

Those circumstances which have been already set forth as
capable of aggravating the secondary diseases of an unsound
heart, are all apt to interpose when such diseases especially
declare themselves through the lungs. And those circum-
stances, already noted as limiting the expectations of medicine
for their relief, are all apt to intrude their counteracting
influence when the special scojje of our treatment is the lungs.

The difierence between one form of unsoundness and an-
other in the heart itself; the presence or absence of coinci-
dent disease in other organs ; the patient's constitutional health,
the state of plethora or anaemia or the state equally removed
frcm both ; the patient's accidental condition respective to ex-
ternal circumstances, whether he be doomed to a life of labour
or can choose a life of ease ; all these contingencies, whose
importance has been anticipated, now find room to make a
signal display of their power.

As to one form of unsoundness in the heart ; if the heart
beat with an excessive impulse yet with perfect regularity and

426 CLINICAL MEDICINE. [lECT. XXXV.

the pulse at the same time be full and strong and steady, the
secondary affections of the lungs (other circumstances being
favourable) are likely to be of easy management for a long
period. The heart is now probably in a state of simple hyper-
trophy. It has gained a simple increase of organic power and
so is acting injuriously upon the circulation ; and the circula-
tion seeks relief through the lungs. Here the treatment is a
treatment of restraint : that treatment which tells most plainly
and speedily upon its objects and is the easiest and simplest of
all modes of treatment. And should there be now a bronchial
or vesicular crepitation of small extent and short standing, it is
remarkable how rapidly it and its attendant dyspnoea are often
swept away by a single cupping. Should the same crepitation
be of larger extent and longer duration, should portions of the
lungs be even condensed, the same treatment repeated may be
trusted for bringing about the same result. And not only this,
but the unsoundness of the heart being a simple hypertrophy
and other circumstances being favourable, affections of the
chest still more formidable are found to admit of abatement or
suspension or temporary removal ; such as habitual or frequent
recurring haemoptysis and hydrothorax. These are the cases
in which the remedial power of digitalis is often eminently
displayed. They are peculiarly the cases for its use. One chief
object of our treatment is (I repeat) to put a restraint upon the
excessive force of the heart's action ; and this our cupping and
our leeches, while they are subsidiary to the lungs in their
present distress, contribute at the same time to effect. And
digitalis effects it by a direct and specific virtue of its own.

But I must not make it an express indication of treatment
in these cases to put a restraint upon the heart's action without
adding this necessary caution. Do not seek to bring down the
impulse of the hypertrophied heart to the level of the healthy
heart. This is not necessary in furtherance of the curative
effect of our remedies. Besides, you can only do it by the
extravagant use of one of two remedies. You must run the
chance either of poisoning your patient with digitalis or of
bleeding him into anaemia.

Further as to another form of unsoundness in the heart ; if
the heart beat with defective impulse and with great irregu-
larity, and the pulse be small and weak and fluttering, then

LECT. XXXV.] THE LUNGS IN HEART DISEASE. 427

the secondary aifections of the lungs, even tliougli other cir-
cumstances bo favourable, are more difficult to manage and
more full of peril. The heart is now attenuated or softened or
it is dilated without a proportional increase of muscular sub-
stance. It has lost organic power.

Now it may pass for a maxim in physic, that weakness is
always less manageable than strength. And here there is
nothing but weakness and the natural result of weakness,
sitffering not acting. Here auscultation may detect the same
conditions of secondary disease within the lungs as in hyper-
trophy. But they are only meclianicaUij the same, they are
vitally different ; and medicine does not promise the same suc-
cess in their treatment. Here as in hypertrophy the respiratory
murmur is obscured or superseded by crepitations of various
degrees and extent. But in hypertrophy the catarrhal and
hfemorrhagic states of the bronchi, the pulmonary and pleural
effusions imply something active and often partake of an
inflammatory character ; whereas here they imply something
inert and passive.

In hypertroph}^ of the heart, or that unsoundness which
increases strength, we treat the secondary diseases of the lungs
by cupping and leeches and counter-irritants, and we look for
some marked and essential relief ; we look for their suspension,
their abatement or temporary removal. — And in attenuation or
softening of the heart, or that unsoundness which brings iveah-
ness, we may still treat the secondary diseases of the lungs by
cupping and leeches and counter-irritants, but we look for
nothing great or striking or complete in the way of relief. It
is enough if, by thus making a new outlet for the jrent up blood,
we succeed for a while in taking off' some part of their burden
from the heart and lungs.

In the case of hypertrophy, while our remedies were ad-
dressed to the special relief of the lungs, I spoke of it being a
further indication of treatment, either by pushing the same
remedies a little further or by the use of others auxiliary to
them, to put restraint upon the force of the heart's action.
But this is the very thing we must guard against in the case
of attenuation or softening. The heart's action wants sustain-
ing and not restraint. While by our cupping and our leeches
we are seeking to take off its burden from the circulation, we

428 CLINICAL MEDICINE. [lECT. XXXV.

must be ready at the same time, if need be, to support and
stimulate it. While the heart is flapping and fluttering and
its feeble movements can scarce be felt, and the blood is almost
stagnant in the vessels going to it and from it, and almost
stagnant in the lungs, we cup and we leech and we may even
venture to use the lancet and let out two or three ounces of
blood from a large vein, but in the mean time we must give our
patient wine or brandy.

Thus, I have taken hypertrophy of the heart on the one
hand, and attenuation and softening of the heart on the other,
for the sake of comparing or contrasting the character and
curability of their secondary diseases which declare themselves
in the lungs. And it plainly appears that they exhibit a great
difference in these respects according as they spring from one
or the other form of unsoundness.

Now the differences here denoted in the character and cura-
bility of the secondary diseases of the lungs, springing from
these two forms of unsoundness in the heart, may be taken to
represent all the differences which can arise, be the form of
unsoundness what it may. For practically and with reference
to their secondary diseases, all forms of unsoundness in the heart
may be reduced either to that which augments or that which
diminishes its organic power. Practically they are all either
an hypertrophy or an attenuation. — They make the heart either
over strong or over weak. Valvular injury of small amount
often stimulates the heart to the exorbitant impulse of hyper-
trophy, though there is yet no hypertrophy in fact. And val-
vular injury of great amount reduces the heart to the feeble,
fluttering, irregular impulse of attenuation, though there is yet
no attenuation in fact. Nay ! valvular injury, when it is such
as to produce extreme constriction of its orifice, will bring an
hypertrophied heart down to the conditions of an attenuated
heart and make it flutter and falter with an irregular and a
scarcely perceptible impulse.

"While, therefore, it is generally true that the secondary
diseases of the lungs take their character and their measure of
curability from the form of unsoundness subsisting in the heart,
it is not 60 strictly true as that they have ahvays one character
and one measure of curability where the form of unsoundness is
the same. It might be so, if all the processes concerned were

LECT. XXXV.] Till': LUNGS IN IIEAIJT DISEASE. 42f)

merely mechanical. But here the mechanical cause works
through a vital aj^ency. The structural unsoundness of the
lieart compels it to a new mode of vital action ; and this it is,
which immoAiatehj determines what the secondary disease of the
lungs shall be. Yet inasmuch as the same form of unsound-
ness (jcncvnlly induces the same mode of action in the heart, it
is gcnerallif safe to refer at once to this unsoundness as if it
immediately determined the character and curability of the
secondary disease of the lungs. But since the same form of
unsoundness, as it may be less or greater, simple or complex,
sometimes induces different modes of action in the heart and the
consequent pulmonary disease affects a different character and
has a different measure of curability accordingly ; it follows,
properly speaking, that the heart's mode of action rather than
the heart's form of unsoundness is the real motive of the
secondary disease and the guide of its treatment.

But have not I been speaking rather too much of the lieart
and the lungs, as if they could suffer together and could (as it
were) bear each other's burdens, and could carry on their
mutual diseases between themselves, other parts of the body
liaving little or no share in the matter ? Perhaps I have.
Medical teaching however, if it is to be useful, must sometimes
be engaged in (what may be thought) an extreme analysis.
For the sake of rendering the nature of disease well understood
it is allowable to seize upon its simplest forms and to make
much of them and to dwell long upon their explanation, before
we proceed to the more complex. No matter, that the simplest
forms are the rarest. They are the rudiments of all the rest ;
and our knowledge of all the rest is based upon our knowledge
of them.

Yet perhaps upon the whole the heart and lungs will be
found to keep their intercommunity of morbid action and
suffering exclusively to themselves oftener and for a longer
time than other organs; and their relative dependency of
function may account for this. But still it must be a small
unsoundness of the heart, which does not make itself felt
beyond the lungs ; and, besides being small, it must be either
stationary or very slowly increasing, still to make itself felt b}^
the luniJ-s, and not beyond them for any considerable period of
a man's life. And, further, the secondary disease or ailment

430 CLINICAL MEDICINE. [lECT. XXXV.

of the lungs must also be of small amount to admit of tlie same
habitual restriction.

And this is really sometimes the case. A small degree of
hypertrophy may be stationary or very slowly increasing for
years, augmenting the natural impulse of the heart at all times
a little, and occasionally a good deal, and hurrying the respira-
tion at all times a little, and occasionally a good deal. So too
a small degree of hypertrophy may be combined with a small
degree of valvular injury and both maybe stationary or increase
very slowly for years ; and for years the consequent suffering
will be restricted to the heart and lungs, and will not exceed
the amount specified in either. A certain degree of attenuation
also may be stationary or very slowly increasing for years,
diminishing the natural impulse of the heart at all times and
occasionally making its beats irregular ; and, though it do not
make itself constantly felt by the lungs, yet it may hinder the
man from any very vigorous or long- continued exertion on
account of shortness of breath. Many people (it is well known)
have an habitually feeble circulation and an occasionally
irregular or intermitting pulse all their lives. Yet they pass
for well, and really are well in their own consciousness, and
live as long as other people. In several such I have convinced
myself (as far as it is possible to be convinced about such a
matter) that their heart has been weak of structure, and of
small size in proportion to their stature ; and it is a curious
fact that most of those in whom I have found this condition of
heart have told me, that they were always short-winded and
that at school they could not exert themselves like other boys ;
they were accounted bad runners. These are small things
indeed ; but they are the elements of greater things, and there-
fore they are worth mentioning.

The brain comes next to the lungs in its ready acceptance
of injurious influences from an unsound heart. Dr. George
Burrows has made good this conclusion by bringing together
the scattered experience of others, and setting it in order, and
testing it, and illustrating it by a larger and better experience
of his own.*

Already I have said something of the troubled functions
of the brain during the actual progress of acute inflammation
* Burrows on Disorders of the CereLral Circulation.

LECT. XXXV.] THE BJBAIN IN HEART DISEASE. 431

in the pericardium, in the cndocarcliura, and in the muscular
structure of the heart, and during the period of their precarious
reparation ; I have spoken of the diversity of form which
belongs to them, and of their perilousness and fatality, and of
the strange disguise of their true origin in the heart under
the more prominent symptoms referable to the brain, such as
delirium and convulsions. Here surely there is more than we
can yet account for from the known pathology of blood and
blood-vessels and from mere derangement of the circulation.

But the heart, in its various chronic forms of permanently
abiding and still increasing unsoundness, does not lose the
power of influencing the brain injuriously and fatally. And
now it is much easier to see it acting through the medium of
the circulation. This is a great subject, and I would willingly
leave it to the lucid exposition of Dr. George Burrows*; but, as
it falls in with my purpose, so perhaps I may be expected, here
to state summarily what I know of it.

I would state then summarily, that it belongs to the heart,
in its different states of permanent unsoundness, sometimes to
affect the brain perilously or fatally, the brain itself being alto-
gether free from disease; and sometimes only to bring the
disease, which already exists within the brain, sooner, and
more inevitably, to a perilous and fatal event. The work may
be entirely of the heart, or it may be shared between the heart
and the brain.

I would mention especially two forms of cerebral affection,
contrasted with each other, and always perilous and often fatal,
which are the entire work of the heart but derived from different
states of unsoundness within it.

The first is apoplectic coma, coming and going (when it
does go) under these conditions. There is stertorous breathing,
and foaming at the mouth and present insensibility, and lividity
of the lips and some distortion of the features. The needful
remedies are applied. As much blood is taken from the temples
by cupping as can safely be borne, and sense and consciousness
are gradually restored, and no paralysis is left behind.

Here neither serum nor blood, I presume, has been let loose
upon the brain. The whole mischief is effected by the blood
still within its proper vessels, by its congestion, retardation, or
* Burrows on Disorders of the CereLral Circulation, p. 105.

432 CLINICAL MEDICmE. [lECT. XXXV.

remora. How this came to pass, the coincident unsoundness of
the heart is ready to explain. The disease consists of passive
dilatation. There is a ventricle (commonly the right) of large
capacity, with such a condition of its parietes as brings loss
of power, i.e. dilatation either without proportionate hyper-
trophy, or with positive attenuation or with conversion of muscle
into fat.

This form of apoplectic coma I have witnessed in many
individuals, and (what is more instructive) again and again in
the same individual. There is great peril in it. The brain
must be set free or the patient will inevitably perish. The
treatment by blood-letting, as far as I know, can alone do this,
and place the patient in present safety. But this treatment
needs great care in the management. Knowing the case I have
had to deal with, and minding to use all needful caution not to
exceed the requisite measure, nevertheless I have sometimes
exceeded it, and my patient after cupping has passed from coma
to convulsions. So difficult is it sometimes to avoid the mis-
chances of a needful remedy !

The other form of cerebral affection in which the brain
suffers secondarily and derivatively from the heart has, as far as
I am informed, been nowhere pointed out. And indeed it is
confirmed to me by much fewer examples which I can call to
mind than the apoplectic coma. Nevertheless, when it does
occur, its character is so plain and unmistakeable, that I cannot
doubt the reality of the thing which I am speaking of.

The heart by the simple vehemence of its action has the
power to kill ; and to kill through the medium of the brain.
The head is racked with continual pain. There is little or no
sleep. The patient becomes delirious, then maniacal, then con-
vulsed, and he at last sinks from exhaustion of his nervous
system.

I have already given a case which had this termlna tion.*
Hypertrophy and dilatation of the left ventricle followed the
xinrepaired effects of acute endocarditis and pericarditis. The
liver had been enormously congested. Fluid had been largely
effused into the cavities of the pleura and peritoneum and
generally into the cellular structure throughout the body. But
liver and lungs and pleura and peritoneum and all the cellular

* Pa^e 199.

LECT. XXXV.] THE BRAIN IN HEART DISEASE. 433

structure had boon unloaded and brought back to the apparent
conditions of health. Thus the patient was set free from the
more formidable consequences of his disease ; and the disease
itself was brought back within the limits of its original seat
in the heart. The same consequences never returned. But in
three weeks more he was dead. lie died in the manner specified.
The heart, I repeat, by the simple vehemence of its action had
the power to kill, and to kill through the medium of the brain.
There are yet other cases in Avhich death takes place through
the brain but by the heart ; through the brain affected a good
deal after the same manner which has just been described, and
IjU the heart acting with the same unappeasable vehemence ;
this vehemence however being induced by other conditions of
disease within it. I have seen a few instances of death from
chlorotic annemia. "What has then been the exact physical
state of the two organs I cannot tell, but the symptoms during
life have taken their direction from the heart to the brain. The
excessive energy of the heart and arteries has sensibly worn out
the brain, and the course of events has followed in this fatal
order ; sleeplessness, delirium, mania, exhaustion, death.

But it has been said that it may belong to the unsound
heart only to bring the disease, which already exists within the
brain, sooner and more inevitably to a perilous and fatal event.
Apoplexies and palsies and epilepsies are thus often shared
between the brain and the heart. There is enough in the brain
to produce them but not enough to produce them yet. There is
enough in the heart to lead to them but not enough yet to
bring them actually to pass. The ossified blood-vessels of the
brain want some unnatural congestion or some extraordinary
impulse, such as an unsound heart can give to the blood within
them, that their disease ma}'' have its present effect in effusion,
or hcemorrhage. And the unsound valves of the heart or its
active or passive dilatation must have their capacity of doing
injury to the brain, helped and exalted by the ossified blood-
vessels of the brain itself.

But the external influence thus fatally felt by the brain does
not always proceed simply and exclusively from the heart.
When the unsound heart does a prior injury to the lungs, then
it and the lungs are apt to work together conjointly to the
further injury of the brain. The brain is racked and exhausted

28

434 CLINICAL MEDICINE. fLECT. XXXV.

by the vehement impulse of its blood-vessels, or oppressed by
their congestion, and thus much it owes to the unsound heart.
But the brain is also poisoned and narcotised by an impure
undecarbonated blood, and thus much more it owes to the
damaged lungs.

Any unsoundness of the heart, which is of considerable
amount and still progressive, is apt to carry its secondary
diseases beyond the lungs and beyond the brain. And, wher-
ever they are found they are still of the same kind, and blood
and blood-vessels are still the agents of them. Thus the liver
is sometimes found filling half the abdomen, and this enormous
increase of its bulk is owing to the accumulation within it of
blood and bile. Such a condition of the liver is the more
especial accompaniment of those forms of unsoundness in the
heart, which arrest the blood in its return through the veins,
of attenuation, of softening, of dilatation without proportionate
increase of muscular power, and of great valvular impediment.

It would carry us beyond our subject to enlarge further
upon these secondary affections of particular organs. But that
which, in the nature of secondary disease, chiefly declares the
all-pervading and all- subduing power of the original malady
of the heart, remains to be considered, I mean general dropsy.

The secondary diseases of the lungs and of the brain carry
with them their own peculiar dangers. For these organs are
eminently vital in their ofiice and use. But the secondary
diseases of the kmgs afibrd the more delicate test (so to speak)
of what is amiss within the heart. Tor both are so strictly
bound together by their relative dependency of function, that
all which goes wrong within the heart, from the least thing to
the greatest, the lungs are ever ready to feel and to show that
they feel. Yet the first appearance of dropsy in distant parts,
while it denotes no present danger and calls for no instant
remedy to save life, proclaims a greater mischief. It declares
the heart fatally damaged as the centre of all life and of all
function throughout the body. " The silver cord is loosed ;
the pitcher is broken at the fountain."

LECT. XXXVI.] DROrSY IX HEART DISEASE. 435

LECTURE XXXYI.

THE NATURE OF DROPSY WHEN IT PROCEEDS FROM AN UNSOUND

HEART. THE PURPOSE IT SERVES. TREATMENT. ITS

OBJECTS. ITS SUCCESS, WHEN THE DROPSY IS SMAI-L, UNDER

FAVOURABLE CONDITIONS. ITS SUCCESS, WHEN THE DROPSY IS

LARGE, UNDER FAVOURABLE CONDITIONS. WHAT THESE CON-
DITIONS ARE IN EACH CASE RESPECTIVELY.

Dropsy is indeed a largo field. But I have only to do with
what is proper to it and to its treatment, when it results from
an unsound heart ; and I will take the best heed I can to keep
within the due bounds of my subject.

Now what is proper to dropsy when it results from an
unsound heart is this, that nature intends by it her own relief,
and in different measures succeeds in obtaining the relief which
she intends. But I can hardly expect you to understand what
I mean without some explanation.

Dropsy consists pathologically of two parts. One part is
the act of separating the serum from the mass of blood, the
other is the accumulation of the serum after it is separated.
The first is the essential morbid process, the disease ; the
second, though it be popularly considered the disease, is only an
unfortunate accident ; for if the general cellular structure and
the circumscribed cavities into which the serum finds its way
had any direct outlet, then there would be no accumulation, and
in the popular sense there would be no dropsy.

When therefore I say that, in cases of unsound heart,
nature intends by the dropsy her own relief, I mean, that she
does so by the essential process of which it consists, not by what
accidentally follows it, which is an undeniable evil. It is good
that the serum should be separated from the blood ; for the
present necessity requires it. But it is evil, that the serum
being separated should accumulate within the body ; for it

436 CLINICAL MEDICINE. [lECT. XXXVI.

harms and hinders the functions of every organ upon which it
rests by bringing upon them an unnatui'al incumbrance.

In speaking of what nature intends it is difficult not to use
language which may seem to favour some foolish hypothesis.
But in point of fact we always must form a judgment of what
nature is aiming at whenever we interfere with what nature is
doing. And as our practice is sometimes right, it is presumed
that a right judgment is both attainable and sometimes attained.

In this dropsy then, which results from an unsound heart,
our views of treatment will be simplified by keeping in mind
these two points, 1st, the relief which is sought by the efi'usion
of serum. Yet 2ndly, the mischief which actually follows its
accumulation.

Rather a subtile refinement, however, perhaps you will say,
thus to claim a character of good in its design for that which
inevitably terminates in evil ! It is like taking a salutary leap
into perdition. But we shall see. Let the matter be taken as
I state it for the present.

In every case of unsound heart the first appearance of the
least dropsical symptom marks an eventful period : it marks
the period when a new law is beginning to take effect in the
circulation and to gain a mastery over the law of health. The
>aw of health of which the sound heart is the prime agent,
retains the blood within the blood-vessels, or dispenses it only
for the needs and uses of health. The new law, of which the
unsound heart is still the prime agent, suffers or forces the
blood or some of its constituents to escape and to form accu-
mulations of serum out of the courses of health.

A little oedema of the ankles or a little a?dema of the face
is a sufficient notice of the first yielding of the blood-vessels to
this new law, which is no other than a mechanical necessity
against which they can no longer hold out. It is the earliest
beginning of serous effusion, which may go on increasing until
it has pervaded the entire cellular structure and filled every
serous cavity of the body.

All this calls at once for medical treatment. But what is to
be done ? The circulation must have the relief it seeks some-
how. Disburden itself it must. There is a physical necessity
in the case from which we cannot set it free. Or if we could,
it must be by interfering remedially with the actuating cause,

LECT. XXXVI.] DROPSY TN TIEAR'J' DISEASE. 437

i.e. by curing the unsound heart. But this is impossible.
What then can be done 't

This can be done and this only. Seeing what nature is
doing and must do, wo can only go along with her and seek to
aid her in accomplishing her own purposes through other and
less hazardous channels. Nature is seeking relief by directly
evacuating the blood-vessels of their contents. We must try
to gain for her the same relief by augmenting natural secre-
tions and so evacuating the blood-vessels through natural
channels. The kidneys and the intestinal canal and its sub-
servient viscera are the most eligible for the purpose.

Here I woidd remark that it is most fortunate when we
have the opportunity of witnessing and treating the dropsical
symptoms of an unsound heart upon their hrst appearance.
Much may now be done for the protection of life by a just
appreciation of what is going on and by skilfully ministering
to it. A swelled ankle or a swelled eyelid is an important
indication of medical treatment in every case of unsound heart,
from the vast meaning which it conveys.

This happy opportunity of treating the dropsical symptoms
of an unsound heart at as early a period as possible is afforded
chiefly by a certain class of patients, by those who are rich and
well-off in this world. Such men, besides the ampler share
they have of the good things of this life, have also readier
means of averting or lessening its evil things. They cry out
as soon as they are hurt, and they no sooner cry than they get
well attended to, and obtain all the aids of medicine, just when
it is most likely to do them good. But the poor man looks
down upon his swelled ankles a long time without complaining.
He hardly cares about the matter, until the swelling reaches
his knees, and seldom thinks of applying for advice, imtil it is
much more extensively diffused.

When, therefore, the happy opportunity just described does
occur, we often succeed in dissipating small dropsical swellings,
or in preventing their increase. And we succeed, not by any
severe discipline long continued but by gentler methods occa-
sionally employed ; by medicine now and then addressed to the
bowels or to the kidneys, which obtain from one or the other for
a few days together discharges, which somewhat surpass the
natural measures of health. The circidation being thus easily

438 CLINICAL MEDICINE. [lECT. XXXVI.

disburdened from time to time, is kept from the necessity of
larger effusion^ and the oedema after the lapse of years, in some
fortunate cases, is still trivial in itself and formidable only
as being inceptive and premonitory of something worse.

Now observe, medicine is here concerned only with one part
of dropsy and that too the easiest to manage. There is only
just visible swelling enough to denote the fact of serum being
in the course of separation from the blood-vessels.

But when we thus succeed in abating or suspending or
entirely removing the dropsical swellings of an unsound heart
from time to time or for a long time together, and when we
thus anticipate or alleviate the miseries of existence and put off
death for years, there must be more in our favour than the
mere fortunate opportunity of commencing our treatment with
the commencement of the secondary disease. The primary un-
soundness of the heart itself must not be of the worst kind ;
neither valvular injury enough to produce great positive ob-
struction, nor attenuation or softening enough to produce great
virtual obstruction. There must be no concomitant disease of
great amount in other internal organs, in the liver, in the
kidneys, in the lungs ; no diffused unsoundness of great
amount throughout the arterial system, no marked consti-
tutional pravity, no decided plethora or anajmia. A moderate
hypertrophy or a moderate attenuation almost stationary or
slowly increasing, with very little valvular injury or none at
all, may be the actual form of unsoundness. This would
impede the circulation enough to call upon nature for relief by
direct separation of serum from the blood-vessels ; while it
might admit of a substituted and less hazardous relief, by an
increase of secretion from organs having a natural outlet.

But the happy opportunity before described is often lost,
and the dropsy from an unsound heart has often proceeded to
large accumulations before its treatment begins. And this
especially happens when the poor man is the patient. The
poor man, the victim of an unsound heart, is often brought to
the hospital having every part of his body, which can contain
eflused serum, already filled and distended with it, yet hitherto
nothing has been done or attempted for his relief. Here medi-
cine has a much harder work to accomplish from the first. It
has both parts of drojjsy to deal with. It has a vast amount of

LECT, XXXVI.] DROPSY IN HKAKT DISEASE. 439

accuiuulatcd fluid to get rid of, and then to prevent it from
accumvdating afresh. Yet it has wonderful success in some
such cases.

Ilere the most jDOwerful remedies given and repeated as
frequently as the strength of the patient will bear, are indis-
pensable to the purpose that wc wish to achieve. Large
dropsical accumulations are seldom drained off, by the opera-
tion of diuretics, through the kidneys alone. They subside
rather under the purgatives, Avhich obtain day after day large
watery evacuations from the bowels.

But a wonderful success (I repeat) is sometimes obtained
even under the disadvantage of late treatment. And, if when
time and opportunity were with us, we had need that the
essential condition of the disease should also favour us, in order
to compass the easier task of keeping down the dropsy which
had only just begun to appear ; surely, when time and oppor-
tunity are now against us, and yet we are able to compass the
much harder task of first getting rid of a largely accumulated
dropsy and then of keeping it down in future, there must still
be some essential element in the case which is greatly propitious
to our remedies.

Recollect all the conditions already mentioned, the particu-
lar form of unsoundness in the heart and the absence of coinci-
dent disease in other organs, which came in aid of the fortunate
opportunity and enabled us to deal successfully with the smaller
dropsy. The same must now be found ready to compensate the
loss of the fortunate opportunity and ready to help us in dealing
with the larger dropsy, or we shall not deal with it successfully.
All these conditions there must be ; and there is as far as I have
seen, and perhaps there must be, something besides.

Now this I have observed. Where the unsoundness of the
heart is the same in kind, dropsy will show itself at different
periods of its progress in different cases ; earlier in one man
and later in another. I do not pretend to explain the universal
reason of such diversity ; but I think I see a reason for it which
will hold good to a large extent. Among the various waj^s in
which the fortunes in life of those, who are the subjects of an
unsound heart, can modify the expectations derived from the
intrinsic conditions of their disease, there is one which is very
remarkable.

440 CLINICAL MEDICINE. [lECT. XXXVI.

In those who are well-off in the world, dropsy seldom
arrives until the unsoundness of the heart has reached the
point, at which the circulation can endure its oppression no
longer without seeking relief by effusion of serum. But in
those who are ill-off, dropsy often appears long before the
imsoundness has reached the point at which it would naturally
and necessarily take place. In the first the injurious operations .
proper to the heart's unsoundness are less accelerated by acci-
dental circumstances, and so its evil consequences and dropsy
among the rest are found to tarry, until it has itself become
absolutely great enough to produce them. In the second its
proper injurious operations are unavoidably quickened day by
day and everj^ hour of the day by accidental circumstances ;
and so a smaller disease in one case is more felt than a larger
disease in the other, and its evil consequences and dropsy among
the rest arrive sooner.

We may well be surprised at the complete success which
occasionally attends our treatment of the vast dropsical accu-
mulations, which accompany an unsound heart. But in such
cases it will be found that, but for the patient's unfortunate
circumstances, there would have been no dropsy at all, the
affection of the heart being not yet ripe for it.

It is within my experience that the same individual, having
an unsound heart, has been received into the hospital again and
again and discharged again and again after the complete cure,
for the time, of vast dropsical accumulations.

A young man, who had been cured before of very extensive
dropsy more than once, and had returned to his occupation,
Avas carried into the hospital now in a state, which seemed
far beyond all hope of relief. His legs and thighs were
immensely swelled, his countenance was dusky, his lips livid,
his eyes vascular, almost starting out of his head, his air-
passages loaded with mucus, his jugular veins prominent,
his heart acting with great vehemence within the chest, and
the pulse at the wrist very small. He was at once moderately
bled from the arm with immediate relief ; and in a few
days he was moderately bled again. Leeches were applied
to his chest. All the secretions of his body were solicited by
suitable remedies. In three weeks he was walking about the
ward and begged to be discharged, thinking himself well. And

LECT. XXXVI.] DROrSY IN ni'LVIlT DISEASE. 441

indeed he had entirely got rid of the dropsy, the cough, the
expectoration, and, in some measure, of the venous congestion.
The lungs Avere freely pervious to air without any unnatural
sound. The symptoms immediately referable to the heart were
the only symptoms which remained ; and these were such as
denoted moderate hypertrophy and a small amount of valvular
disease. The secondary diseases, the dropsy and the bronchial
and pulmonary congestions and inflammation and catarrh, had
all come on prematurely. He would have had none of them if
he had not been obliged to labour for his bread.

At the time this young man was admitted into the hospital
and all the while he remained with us, and still after he left
us, there was in the same ward a little boy. And the little boy
lay in the next bed to him, and saw him brought in in a dying
state, and witnessed how every remedy told for his relief; how
day bj^ day he became better and better, until all his dropsy
and all the anguish of his chest were gone, and he could now
walk about like other men ; and how in a few weeks he left the
hospital apparently well.

Now the little boy had the same disease as the young man.
His whole body was dropsical, his heart beat with a violent
impulse, and he had great anguish of respiration. And, when
I came to his bedside each day and still found him no better, I
fancied by his looks that he was ready to say, " And why can-
not you cure me as well as him ? I am not as ill as he was.
But now he is well, and why am not I well also r' " It is true,
that there was in the little boy a less amount of secondary
disease, less of dropsy and of pulmonary congestion and catarrh
than in the young man, but there was a greater amount of
unsoundness in the heart. Yet it was the same in kind ; the
symptoms immediately referable to the organ denoted great
hypertrophy with valvular disease. No medical means pro-
cured him more than a very slight and a very brief alleviation
of sufiering. And he died.

More, much more, might be said upon this subject of
dropsy, as well as of the other secondary diseases, proceeding
from an unsound heart. But I must keep within reasonable
limits, and be content rather to fix attention on what is most
desirable to be known, than wish to say every thing that can
be said.

442 CLINICAL MEDICINE. [lECT. XXXVI.

As to the management of these same secondary diseases, I
have dwelt more upon principles of treatment than upon par-
ticular remedies. For congestions, effusions, haemorrhages and
inflammations, from whatever cause they spring, our remedies
are numerous enough. Indeed I wish they were fewer. For
then, perhaps we shovild better understand their use and do
more good with them in the end. The difficulty is not so much
to find a remedy as to choose one.

And indeed for congestions and effusions, haemorrhages and
inflammations, when they proceed from an unsound heart, there
is less need of seeking distinct and appropriate remedies. As
they come from a common cause, and are of a kindred nature,
and are apt to occur together or interchangeably in the same
subjects, so we are much oftener called upon to treat them
together or interchangeably by the same, or by little variation
of, remedies, than to treat them one by one, as separate results,
each by a remedy proper to itself.

Such is the best summary I am able to give, within the
compass which I have allowed mj^self, of this very large subject,
comprehending the manner in which unsoundness of the heart
in its various forms makes itself felt in the vascular system, and
through the vascular system in every organ and in the functions
of every organ ; and how thus it gives occasion to various kinds
of secondary disease. I have wished to make my smnmary a
fair transcript of the truth. But there is a certain imperfection
in our knowledge of all these matters which we have been
handling, rendering it a difiicidt task to give such descriptions
of them as will be at once seen and recognised as true.

There is that in the nature of chronic disease, which makes
it only haK disclose itself. It discloses itself only in its results,
and not in its operations. Whereas acute disease discloses itself
in both. The knowledge therefore, which we have of chronic
disease, is only a half knowledge compared with what we have
of acute. In chronic disease we see only what it has done, not
what it is doing ; in acute disease we see both.

Coleridge, in one of his profound moral sjjeculations, speak-
ing of the difference between the secret and slow- working in-
fluences, which imperceptibly change men's opinions and pro-
fessions, and those violent motives which revolutionise them at
once, makes use of this beautiful illustration : " The difference

LECT. XXXVI.] DEOrSY IN HEART DISEASE. 443

is merely tliat between the hour hand and tliat which tells the
seconds on a watch. Of the former you can only tell the past
motion ; of the latter botli the past motion and the present
moving'." Just such is the difference between chronic disease
and acute. Of the former you can see only the past effect ; of
the latter both the past effect and the present effectuating.

35ut not only is the task of describing chronic disease ren-
dered difficult from the imperfection of our knowledge, but also
from the manner in which such knowledge as we have must
needs be obtained.

We learn acute disease from seeing it as a whole ; from
seeing it as it is acted and suffered through all its stages by the
same individual men and women. Being an affair of a few
days or a few weeks only, we are often present as eye-witnesses
of it from first to last. Thus our loiowledge of it is drawn
from single and complete histories. And a few cases well
watched and remembered are enough to make that knowledge
of considerable amount.

ISTow the mode of obtaining our knowledge being thus easy
and summary, the mode of imparting it need be no less easy and
summary in its turn. And so the description of acute disease
is never difficult, if the describer, mindful that his own know-
ledge of it came to him by the simple observation of closely
consecutive facts, be content to give a simple and consecutive
account of them.

But it is very diflferent with chronic disease. We do not
learn it from seeing it as a whole, as it passes through all its
stages in the same individual men and women. Being an
affair not of days or weeks, but of months and many months,
and oftener of years, and oftener still of many years, we are
indeed very seldom present as eye-witnesses of it from first to
last. Thus our knowledge of it is not drawn from single and
complete histories, but put together piecemeal from numerous
imperfect ones. And after all we get more knowledge com-
plete and at once from a single case, when the disease is acute,
than we gather piecemeal from twenty, when the disease is
chronic.

Now of knowledge so obtained it is very difficult to give a
consistent and summary account. And thus a description of
chronic disease can hardly be made intelligible without some

444 CLINICAL MEDICINE. [lECT. XXXVI.

artifice or management, whicli may prejudice its truth. The
most useful and perhaps only just representation that can be
made of chronic disease is not in the way of description but of
commentary ; of commentary upon the great facts arising in
the course of its duration, which mark its periods and stages ;
which denote its pauses, its retrogression or its advance ; which
furnish indications of treatment ; which announce its invasion
of important organs or systems of organs, and the holding out
or surrender of the sources of life.

LKCT. XXXVI r.] ANGINA PECTORIS. 445

LECTURE XXXVII.

AFFECTIONS OF THE HEAllT, CONSISTING IN A CERTAIN ASSEM-

HLAGE OF SYMPTOMS, NOT IN EXPRESS FORMS OF DISEASE.

GENERAL REMARKS UPON THEM. THEIR PATHOLOGICAE

CHARACTER. THEIR TREATMENT. ANGINA PECTORIS. ITS

PATHOGNOMIC SYMPTOMS. ITS EFFICIENT CAUSE ; NOT AN-
NEXED TO ANY ONE FORM OF UNSOUNDNESS IN THE HEART,
BUT PROBABLY PRODUCED BY SPASM, WHICH IS INCIDENT TO

MANY. SUDDEN DEATH WITHOUT PREVIOUS ILLNESS. CASES.

PROBABLE CAUSE, SPASM OF THE HEART, OR A FIRST ATTACK

OF ANGINA PECTORIS.

An interesting portion of our subject yet remains, whicli will be
found different from those portions of it hitherto considered, as
in other respects so chiefly in this, that it has a less objective
character.

The practical purpose of these lectures has required us all
along to look at diseases of the heart through their living
developments. We have indeed regarded them in different
lights and perspectives and from opposite sides, and near and
from a distance, but always through the medium furnished by
living circumstances. For what has their clinical diagnosis
comprised, but the nearest living manifestations of their actual
presence ? and what their clinical history, but those prior and
accompanjdng conditions in the life and health of the patient,
which were found variously leading to and variously promoting
and causing them ; as well as all those subsequent conditions in
the life and health of the patient variously springing /ro;;^ them
and variously promoted and caused hi/ them ? and what was
their treatment conversant with, but the means of influencing
those same conditions and of influencing them for good ?

But, withal, we have never lost sight of the objective reality
of the diseases themselves. "We have had by turns present to
our minds an endocarditis or a pericarditis ; a stricture at this

4^6 CLINICAL MEDICINE. [lECT. XXXVII.

or that orifice, an unsoundness of this or that valve ; an inflam-
mation or suppuration, an ulceration or a rupture of the heart's
muscular substance ; its hypertrophy or its atrophy, its softening
or its dilatation.

As we have dealt hitherto, so we would continue to deal
with our subject. But what if our subject, in much that
remains of it, will not so be dealt with ? We would still look
through their living developments at the diseases themselves. We
would still bestow our chief care where we did before, and be
found grouping and analysing symptoms and calculating what
they mean as notices of something beyond themselves and as
guides of treatment ; but reserving the name and character of
diseases for those sure and more definite objects from which
they issue as natural results and emanations.

But what if none such can be found ? What if, beyond
those living manifestations which properly bear the name and
character of symptoms, we discern darkly only and doubtfully
or not at all, any surer objects which can bear the name and
character of diseases ?

Why then we must be content to rest in the symptoms, and
to bestow some summary or generalising name upon them, as if
they were the disease. They indeed are not the disease, and we
know that they are not. Yet in attemptiug to look through
them and beyond them we gain so questionable a vision of what
the disease really is, that we act wisely in stopping for the
present where our knowledge stops, or in being cautious at
least that the terms we use do not import more than we
understand.

There is one eminent instance in which an assemblage of
symptoms is thus made to bear the name of a disease ; angina
pectoris. This angina pectoris has existed indeed where there
has been ossification or obstruction of the coronary arteries,
where there has been dilatation of the aorta, where there
has been valvular imsoundness, or hypertrophy or atrophy,
or softening or conversion of the heart's muscular substance
into fat. It has been coincident with one and one only of
these forms of disease or disorganisation or with two or more of
them in combination. And it has existed where no form of
disease or disorganisation whatever has been found either in
the heart or in the blood-vessels nearest to it.

LECT. XXXVII.] ANGINA rECTORIS, 447

Our knowledge tlicn of angina pectoris stops short witli its
symptoms. The idea of it cannot be made to rest in any defi-
nite form of disease beyond them. We are sure of what it is
as an assemblage of symptoms. We are not sure of what it is
as a disease.

There is an use sometimes in thus measuring the limits of
our knowledge. In a profession like ours it is not enough to
lament its imperfections. We should rather seek to understand
wherein they consist, and so learn to bear with them and to
make the best of them.

Medicine is a strange mixture of speculation and action.
We have to cultivate a science and to exercise an art. The
calls of science are upon our leisure and our choice ; the calls of
practice are of daily emergence and necessity. Science may
minister to practice much or little. But whether science help
lis or fail us, whether its instrumentality be sufficient or defec-
tive, still we must act. We are bound to the constant endeavour
of doing the best we can whether upon a perfect or an imperfect
knowledge.

The imperfection of our knowledge, now especially pointed
out, is, where all our pretensions to be exact must rest in the
character of the symptoms and cannot reach to the nature of the
disease. But let us be just at least to such pretensions, and not
run away with the notion that this knowledge is no knowledge
at all. For the fact is far otherwise. Often indeed, where
there is much more knowledge besides this, yet is it this and
this only that can be made use of; and all the rest goes for
nothing when we come to seek for guides and indications of
treatment.

Think what symptoms are. They are not mere signs of the
disease, but they are direct emanations from it ; not things in
themselves nugatory but eminently real. They are natural sen-
sations unduly exalted or unduly depressed or variously changed
or perverted. They are natural functions hurt, hindered or
abolished. So that a man may often with stricter propriety be
said to be ill of his symptoms than to be ill of his disease, and,
what is more, to die of his symptoms than to die of his disease.
Accordingly it often happens, even where the disease is best
understood, that we treat the symptoms and the symptoms only,
just as if we had no knowledge of any thing beyond them.

448 CLINICAL MEDICINE. [lECT. XXXVII.

Therefore, when we have confessedly no strict knowledge of
any thing beyond them and the aim of our practice must needs
centre in the symptoms, we are not to lament over the short-
comings of our art and its straitened capacity of doing good.
For it does not follow, that, if we knew the disease ever so well,
we could treat it otherwise than we are now treating its
symptoms, or that what we are now doing for the symptoms
would not be the best and would not be all, that could be done,
for the disease itself.

Some remarks have already been made upon pain referable
to the heart ; to the effect that it was a very uncertain guide to
the diagnosis of its diseases, and a very uncertain measure of
their sevei'ity. For in some of the most formidable, as endocar-
ditis and pericarditis, though pain was generally present, it was
sometimes entirely absent, and, being present, it was often of
small amount when the disease was severe, and often of great
amount when the disease was trifling.

But pain with one awful accompaniment may be every
thing ; the prominent and all-absorbing symptom ; denoting
the disease, and measuring its severity. So that the very disease
itself is called pain, angina pectoris or pain of the breast.

Now none can well describe the quality of a pain but those
who have felt it. And the subjects of angina pectoris report,
that it is a suffering as sharp as any that can be conceived in
the nature of pain, and that it includes moreover something
which is beyond the nature of pain, a sense of dying.

This angina, this mixture of the sharpest pain with a feeling
of instant death, has its seat in the upper, the middle or lower
part of the sternum ; it passes through the chest to the spine,
often inclining more to the left than to the right side. It
comes suddenly and goes suddenlj^ This is all which constantly
belongs to the disease.

Its definition might run thus. Pain of extreme severity
passing through the chest from the sternum to the spine,
arising suddenly and ceasing suddenly, and accompanied,
while it lasts, with a feeling of approaching death. JN^ow,
although I have no great opinion of definitions for the use they
serve in medical teaching, and am quite sure that their adop-
tion generally for this purpose would convey very cramped
notions of disease, yet there are good reasons for speaking

LECT. XXXVII.] ANGINA PECTORIS. 419

very carefully (if not logically) on our present subject. Angina
pectoris from the time it was lirst described by Dr. Ilebcrdcn
has always had a large share of attention paid to it. Much
has been written about it, and well written, by some of the
best men in our profession. But it is still of very doubtful
pathology ; and its pathology has little chance of being further
illustrated, unless there be a clear agreement among us what
we are to understand by the thing itself.

There is a form of dyspnoea which, from its suddenness, its
severity and the pain of approaching death which attends it,
is V ery apt to be confounded with angina pectoris. From what
I read in books and what I hear in my intercourse with medical
men I suspect that they both pass popularly for the same thing.
But it is most needful that our ideas of each should be kept
separate. As angina pectoris may in certain cases be comj)li-
cated with many affections with which it has no necessary con-
nection, so it may with dyspna-a. But the two are naturally
distinct, and the first and best writer upon the subject emphati-
cally marked the distinction.*

I believe that the definition, which has been given, includes
all that is proper to angina pectoris and excludes all that is
not ; and that it consists essentially of pain in the chest and a
sense of approaching dissolution. Not from the absolute con-
stancy but from the very great frequency of its occurrence
there is one more element, which has a claim to be considered
almost as a part of the disease. Its very peculiarity forces it
ujjon our notice. It is an extension of the pain to one or both
arms, most frequently to the left and stopping at the elbow,
sometimes to the right, and sometimes to both and sometimes
reaching to the fingers.

But what is angina pectoris ? Its symptoms, striking and
definite as they are, do not carry their own interpretation
along with them. They tell neither whence they are, nor what
is their efiicient cause. Towards such information we must
o-ain what help we can from the many circumstances which
various clinical histories and various dissections have disclosed.

* Initio liujus asgritudinis csetera omnia homines valent ; et seorsim
nulla tenentur spirandi difficultate, a fj,ua hie ijectoiis anger prorsus est
diversus. (Heberden. Comment. 309.)

29

450 CLINICAL MEDICINE. [lECT. XXXVII.

And there are plenty of siicli histories and dissections upon
record. I have both seen many and read many.

But all the cases, which one sees or reads of a particular
disease, do not necessarily add to our knowledge. They may
make knowledge which we have more familiar without augment-
ing it. They may freshen our experience without enlarging
it. Yet some one case out of many, from peculiar circum-
stances belonging to it, may teach us something, which we did
not and could not learn from all the rest.

Thus I have three cases of angina pectoris to report, two
falling under my own observation and the third coming to me
upon the best authority, which added something at least to mij
knowledge of the disease.

R. R, was apparently about 50 years of age. I saw him
for the first time in January, 1837. He looked perfectly well;
but said that he had two complaints for which he wished to
consult me. One was a Kttle teasing cough which only came
on at night and prevented sleep. It was all that remained of
an attack of influenza he had sufiered. He made light of
it and said, he should not have thought of troubling me about
it, if it had not interfered with his rest. The other complaint
he feared was something more serious which he would rather
talk over leisurely with me the next day. But before I left
the room, he gave such a sketch of a paroxysm of angina pectoris
as could not be mistaken. I merely ordered him an opiate
to take at night.

The next day I found that he had slept well in the night
and that his cough had left him. And now he described more
at large "the other complaint" which he had suffered and at
which he could not help being alarmed. He dwelt upon the
agony of pain in the sternum, the sense of approaching death and
the pain in the left arm, and then his instantaneous and perfect
recovery. Hitherto he had consulted no medical man about it.
He did not know what it was ; but his ovm feelings had awakened
his fears, and he believed it to be something formidable.

Now this gentleman had during the preceding summer
made a walking tour through Switzerland, during which he
experienced no bodily inconvenience, and had returned home
as well as ever he was in his life, and then he had, according
to his custom, had his full enjoyment of shooting during the

LECT. XXXVII.] ANGINA PECTORIS. 451

Autumn. In short, until a fortnight ago he had not liad a
feeling about him which gave him the slightest hint that lie
was not in perfect health. It was but a fortnight ago, while
walking up the hill towards Ilampstead, that he had his first
paroxysm of angina pectoris. During this short fortnight the
paroxysms had been increasing in severity and frequency. At
first they occurred every two or three days, then daily and
now several times a day ; at first with, and now without, an
exciting cause.

I made a very careful examination of his chest. The respi-
ration was perfect. The heart was free from all unnatural
murmurs. Its beats were quite rhythmical. The exceeding
feebleness of its impulse was all that deserved notice.

I saw him again in the afternoon of the next day, when he
described to me a paroxysm, which he had suffered in the
morning, severe beyond all his former experience. But it had
entirely passed away, and he now looked quite well.

What I heard to-day made me quite alive to the extreme
peril of my patient. He was a stranger to me, jet I felt
uncomfortable at the probability of his dying under my care,
before I had made any communication of his dangerous state
to his friends. So before I left the house I obtained the
address of his brother, to whom I determined to write as soon
as I got home. It was an hour however before I reached home,
when I found a messenger waiting to announce to me, that,
soon after I left him, my patient had been seized with another
paroxysm and died at once.

Upon examination after death the heart was of its natural
size, its cavities of their natural capacit}^, its walls of their
natural thickness, and its internal lining and valves bearing no
marks of disease. Its muscular substance was more loose of
texture than natural, but not softened in an extreme degree, and
both its coronary arteries were entirely converted into calcareous
tubes as far as they could be traced. The aorta throughout
the chest and the abdomen did not present the smallest space
free from disease. In some parts calcareous matter was
deposited between its coats, in others cartilaginous, and in
others a matter between cartilage and bone. This disease,
besides destroying the elasticity of the aorta at every part, had
greatly narrowed its calibre at a small space of its descending

452 • CLINICAL MEDICINE. [lECT. XXXVII.

portion witliin the chest and so produced some real impediment
to the passage of Wood. TVe did not examine the state of other
blood-vessels. Other viscera of the chest and abdomen were
healthy, excejDt that there was a close and complete adhesion
of the pleura of the right lung to the ribs without the least
ajDjDarent detriment to the lung itself.

There was nothing extraordinary in this case as far as the
mere symptoms went. These ran exactly parallel with the
definition. They were neither more nor less than the disease,
and so taught me nothing which I did not know before. But
there was still a circumstance in the case Avhich was new to me.
It was this ; the brief period that intervened between the
paroxysm first denoting the patient's disease and the paroxysm
of which he died ; between the first paroxysm and the last.
In a first well-marked paroxysm of angina pectoris befalling a
man apparently healthy I should have seen the harbinger of
almost certain death, but, reh^ng upon what experience had
taught me, I shoidd not have expected the fatal paroxysm to
arrive for years. But here it arrived in a fortnight.

I make no observation upon what dissection disclosed in this
case at present.

J. C. was 64 years of age, a robust man in a humble con-
dition of life. I saw him for the first time, and once only, on
the 25th August, 1841. He was in bed, lying on his back with
a countenance expressive of the sharpest pain. The pain he
described as passing from the upper part of the sternum
through the chest to the back, and down both his arms to the
tips of his fingers. His complexion was not paler than
natural, and his respiration was a little, and only a little,
hurried. Altogether he had the look of a man who must
quickly die, if he was not quickly relieved. The relief came in
a few minutes and he was able to answer questions.

Auscultation found his heart beating with a perfect rhythm
and neither with excess nor defect of impulse. Its sounds
were natural but loudly intonated and conveyed over the front
of the chest far beyond the praccordial region. The respira-
tory murmur was vesicular, clear, and unmixed, throughout
both lungs, except perhaps at a small space of the lowest part
of the right, where it seemed not quite so free as elsewhere and
was accompanied by a very slight sound of moisture.

LECT. XXXVII.] ANGINA PECTORIS. 453

This man until within eight days had believed himself in
perfect health. His first attack was on the IGth. It came on
without any apparent cause, and, by the account of his medical
attendant, was a genuine j^aroxysm of angina pectoris. His
second was on the 20th. From that time tlie paroxysms (it
was said) were many every day and many more every night.
The change from the erect to the recumbent posture always pro-
duced them. That which I witnessed was caused by his going
to bed for me to examine him. Their duration was between
five and ten minutes. The day after I saw him he had eight or
nine paroxysms, and the next day at 2 a.m. ho died. The period
from his first attack to his death did not exceed ten days.

An examination of the body was made on the day of his
death, when the pericardium was found to contain two ounces
of clear serum, and upon its surface covering the heart it pre-
sented a few small white spots. The heart itself had an ap-
pearance of general enlargement. Its internal lining and all
its valves were healthy except that the processes of the mitral
valve might be thought a little thickened, but not so as to
hinder the circulation. The coronary arteries too were quite
healthy. But the muscular substance of both ventricles was
so soft as to be pierced through with the slightest pressure of
the finger. The aorta was entirely free from all morbid
deposits. Both pleura) were free from adhesions and contained
no fluid in their cavities. Both lungs were entirely healthy and
so were all the abdominal viscera.

This case like the last jn-esented nothing extraordinary in its
mere symptoms. But it, like the other, had one extraordinar}'
circumstance belonging to it ; the short, even the shorter,
period that intervened between the first paroxysm denoting the
patient's disease and the last of which he died. In that case
it was a fortnight, in this it was ten days only.

The next case I did not see. But I give its interesting and
sad particulars from the best authority.

T. A. was within a day of completing his 47th year. Up
to a very few hours before his death, both body and mind
seemed equally to give proof and promise of health. He still
took his accustomed pleasure and refreshment in strenuous
exercise. His thoughts were still busily employed upon the
highest subjects, conceiving and composing with wonderful

454 CLINICAL MEDICINE. [lECT. XXXVII.

ease, rapidity, and power. He retired to rest at midniglit on
the 11th of June, 1842, feeling and believing himself to be in
perfect health. At a quarter before seven the next morning
his medical attendant was called. What had previously-
occurred and what followed I will give in the words of Dr.
Bucknill who was with him during the short remaining period
of his existence. " On my entering his room he said that he
was sorry to disturb me so soon ; and that he had not sent for
me before, thinking that it would go off. He added, ' I have
had very severe pain in the chest since five o'clock at intervals,
and it gets worse I think.' This pain was seated at the upper
part of the chest towards the left side and extended down the
left arm. He had been rather sick. He then asked me what
the pain was. ' What is it ? ' He was now almost free from
pain. His pulse I could scarcely feel. The tongue was clean.
There was cold perspiration over his face. The feet and legs
were cool. The breathing at this time not troubled. I gave
him immediately some hot strong brandy and water, and having
ordered a mustard plaster for his chest, till this was ready I
applied hot flannels and had his legs and arms rubbed, and
the feet wrapped up in flannels wrung out of hot water and
mustard. The pulse became natural, the extremities more
warm and he was free from pain. The mustard plaster was
brought and put on. It was not large enough and I ordered
another. The pain then returning I gave him more brandy
and water, and it soon left him. And now he asked me again
what the pain was. I told him I believed it was spasm of the
heart. He exclaimed, ' Ah.' I asked him whether he had ever
fainted in his life ? ' No, never.' If he had at any time difii-
culty of breathing ? ' No, never.' If any pain in his chest
before ? * No, never.' I then asked him, if any of his family
had ever had any disease of the chest ? ' Yes, my father had ;
he died of it.' He inquired if disease of the heart was sud-
denly fatal? I answered that it was. 'Was it a common
disease ? ' I said not very common. * Where do you find it
most ? ' * In large towns I think.' * Why ? ' ' Perhaj)s from
anxiety and eager competition among the higher, and intem-
perance among the lower classes.' He was then quiet and free
from pain and I proposed to leave him for a minute or two.
He had no pain whatever in my absence. On my return the
perspiration was still in drops upon his forehead. The pulse

LECT. XXXVII.] ANGINA PECTORIS. 455

was again feeble and I gave him more brandy and water and
had the flannels with mustard renewed. An attack of pain
was coming on. He said, ' I must stretch myself.' I took one
of his hands and held it until the pain was gone off. It was of
short duration. I said, is it gone ? He answered, ' Yes,
entirely,' adding that he ' could scarcely bear it if it were as
severe as it had been.' He then asked me ' what was the
general cause of this kind of disease.' — He then said, * is this
likely to return ? ' I answered that I was afraid it was, but
that, as the attacks had been less severe and less frequent, I
hoped they would pass off. He next asked me if the disease
was generally suddenly fatal. I said generally (for those who
knew him were aware that it was impossible not to tell him the
exact truth). I then asked him if he had any pain. He said,
^ none but from the blister ; one can bear outward pain, but it is
not so easy to bear inward pain.' I was now dropping some
laudanum into a wineglass, when he inquired what I was going
to give him. I told him laudanum, Hoffman's anod^'ne, and
camphor. And, while I was preparing the mixture and before
I had finished, I heard a rattling in the throat and a convulsive
struggle. I called out, and on turning to him I supported his
head, which was thrown back, on my shoulder. His eyes were
fixed and his teeth set, and he was insensible. His breathing
was very laborious, his chest heaved and there was a severe
struggle over the upper part of the body. His pulse was im-
perceptible, and after deep breathings at a few prolonged inter-
vals all was over. He died in little more than half an hour
after I first saw him.

" The examination of the body was made forty-eight hours
after death, the weather being very hot. Its external appear-
ance evinced rapid decomposition. It was discoloured and very
livid in many parts. The skin was tightly distended with air,
which was found in the cellular tissue throughout every part.

" When the right cavity of the chest was punctured a great
quantity of air rushed out. The lungs on this side were
healthy but their posterior part was gorged with blood and
serum, and about eight ounces of bloody serum were found in
the cavity of the pleura. On the left side were some old but
not extensive adhesions of the pleura and about the same quan-
tity of bloody serum was in this cavity as in the right. The
lungs on the left side were healthy but more extensively gorged

45G CLINICAL MEDICINE. [leCT. XXXVII.

with blood and serum than on the right. Posteriorly they
resembled soft sjDleen.

" The pericardium was healthy. It contained about an
ounce of serum of a straw-colour. The heart was rather large.
The external surface was healthy. It was very flaccid and flat
in its appearance. It contained but little blood, and that was-
fluid. There were no coagula of any kind in it. All the valves
were quite health}^ and so was the lining membrane throughout.
The orifices of all the great vessels were quite natural. The
muscular structure of the heart in every part was remarkably
thin, soft and loose in its texture. The walls of the right ven-
tricle were especially thin, in some parts not much thicker than
the aorta, and very loose and flabby in their texture. Its cavity
was large. The walls of the left ventricle too were much
thinner and softer than natural. And the muscular flbres of
the heart generally were pale and brown. The aorta was of a
brown-red colour throughout its internal surface, probably
from putrefaction. A few slight atheromatous deposits were
observed in the descending thoracic aorta. The pulmonary artery
was of the same brown- red colour with the aorta. There was
but one coronary artery, and, considering the size of the heart,,
it appeared to be of small dimensions. It with some difficulty
admitted a small director. It was slit open to the extent of
nearly three inches. Its internal surface was red but healthy
with the exception of a slight atheromatous deposit situate
about an inch from the orifice of the artery. This however did
not appear to diminish its cavity.

" The liver was pale and rather small ; the gall-bladder was
distended with yellow bile ; the spleen was very soft and blood}'.

" The stomach and intestines were distended with air. The
kidneys were solt and rather bloody, and their surface presented
in some degree the mottled appearance known by the term
* Bright's kidne3^'

" The head was not examined. From the absence of all
symptoms of disease in the brain to the last moment of exist-
ence there was no reason to believe that anything unhealthy
existed in the head.

(Signed) " S. Bucknill.

"H.B. Bl-cknill, M.D. ) ^'""S^y-
" J. Hodgson, Birmingham."

LECT. XXXVIL] angina PECTORIS. 457

13iit neither did this case present anything extraordinary in
its mere symptoms. Each paroxysm was a genuine paroxysm
of angina pectoris and nothing more. But the rapidity with
which one paroxysm followed another, and the very brief
period between the first which declared the disease and the last
which killed, these were indeed extraordinary circumstances.

Here then are three cases of angina pectoris. In the first
we have death in a fortnight ; in the second death in ten days ;
in the third death in less than three hours, from the first
seizure. Now circumstances cannot be conceived more favour-
able than those which these three cases present for ascertaining
the connection between symptoms declared in the living, and
changes of structure found in the dead. The symptoms were
essentially the same in all. They were few and striking and
constituted of actions and sufferings which manifestly could,
and manifestly did, cause death. They were also uncompli-
cated, no other symptoms interfering to spoil the simplicity of
each case, before death arrived.

In the two last of these cases one structure of the heart and
one only had undergone morbid change. Its muscular sub-
stance was reduced to an extreme degree of tenuity and softness
In the first more than one structure had suftered. Its muscular
substance was looser of texture than natural, but was not
softened in any greater degree. Yet, moreover, its coronary
arteries were entirely converted into calcareous tubes as far as
they could be traced, and so was the whole aorta too. I have
no doubt whatever that out of these states of disease arose the
fatal angina in each case respectively.

But there is a much larger question which pathologists and
physicians wish to settle. — It is this. Is there any form of
organic disease which can be regarded as the efiicient cause of
angina pectoris absolutely and at all times ; and if so, what is it ?

Now let us look a little farther into the disclosures of morbid
anatomy, and then, comparing what has been found in cases of
longer duration with what we have seen in cases of rapid
fatalit}^ try whether we can come at any sure result.

The cases of longer duration are ver}^ puzzling in all that
respects their morbid anatomy. Alterations of organic form
and texture, which are very simple at first, come to be very
complex in process of time. This happens especially with the

458 CLINICAL MEDICINE. TlECT. XXXVII.

heart. And, when in the heart the organic changes are many
and belong to several structures, it becomes hardly possible to
know what share we should assign to one, and what we should
deny to another, in the production of certain symptoms during
life. This happens especially in long-standing cases of angina
pectoris. Some part of the complex disease found after death
must (we conceive) have existed from the beginning, and been
the efficient cause of the first paroxysm which occurred years
ago, and of the last which occurred to-day, and of every
paroxysm in the intervening period. But which that part is,
who can tell without some clue to unravel the matter beyond
what the morbid appearances themselves supply ?

But in almost all the cases of angina pectoris on record
death has been postponed for years, and in almost all, dissection
has disclosed very complex disease of the heart and large blood-
vessels. The three cases, therefore, which I have reported,
become very interesting from their fatal rapidity. And per-
haps they may have a further value from their simplicity, if
they are found to throw light upon those numerous cases of
the same disease, which are all too complex to be understood of
themselves.

If in those, who die at a very early period after the first
attack of angina pectoris, some one simple change of structure
were uniformly found, and if in those, who die at more advanced
periods, the changes of structure, though ever so multiform and
complex, always included the simple form of organic disease,
which belonged to the malady when it is more rapidly fatal, then
would angina pectoris be fairly traced home to its efficient cause.

There are no cases upon record in which death followed the
first accessions of angina pectoris so rapidly, as in those three
which I have related. And if the disease essentially proceeds
from any material element which morbid anatomy can detect,
these were the cases in which to find it. You know what teas
found in these cases. Unfortunately for the success of our
inquiry, not the same thing in all. Extreme muscular attenua-
tion in two, and muscular attenuation of less degree conjoined
with ossified coronary arteries and an ossified aorta in the third.
But had there been simple ossification of the coronary arteries
in all or simple muscular attenuation in all, yet could neither
one nor the other be regarded as the proper efficient cause of

LECT. XXXVII.] ANGINA PECTORIS. 459

angina pectoris. For though one or both arc often traceable
among the complex forms of disease found in those who die at
later periods, yet one and both are often entirely absent.

What then have these cases, so new and interesting in their
details, taught us after all ? Truly nothing which, upon a
comparison with other cases, goes to establish a purely organic
or mechanical theory of the disease. But they have taught us
much, very much, if, not looking beyond the actions and suf-
ferings of the paroxysm, we regard them as constituting tJte
disease. They have taught us that angina pectoris has a
greater, an earlier, and more instantaneous power to kill than
it was ever hitherto thought to have, and they have so far
enlarged our knowledge of its clinical history, and have thus
enabled us perhaps better to understand its real nature.

What then is its real nature ? Dr. Heberden, after vast
clinical experience of the disease (for he believed that he had
seen more than a hundred cases), and after observation enough
of it in the living man, reports " that it seems to pertain to
distention and not at all to inflammation."*

Do not smile at this old-fashioned phraseology of Dr.
Heberden or at me for quoting it. The writers of Dr. Heber-
den's time spoke of ^'distention " without any precise meaning.
Not so Dr. Heberden himself ; who in this place evidently
meant by " distention " what we understand by spasm ; and
by inflammation evidently meant inflammation both in its pro-
gress and in its results, and indeed all that we understand by
'' Organic Diseased

Then Dr. Heberden proceeds to give his reasons why angina
pectoris " pertains" to spasm and not to organic disease, thus : —

1. It comes suddenly and goes suddenly.

2. It has long and complete intermissions.

3. Wine and spirituous drinks and opium afford great relief.

4. It is increased by mental agitation.

5. It exists for years without other injury of the health.

6. At first it is not excited by exercise in a carriage or on
horseback, as is usually the case with scirrhus or inflammation
(organic disease).

7. The pulse is not quickened in the very paroxysm.

* Angina pectoris, quantum adhvic illius naturam intellexi, ad disteu-
tionera, non- autem ad inflammationem videtur pertinere .

460 CLINICAL MEDICINE. [lECT. XXXVII.

8. The paroxysm attacks some after their first sleep ; a fre-
quent event in diseases which proceed from spasm.*

Surely there is matter of fact and solid sense in all this.
IN'evertheless it does not prove quite as much as it was thought
to prove. Grant that angina not merely pertains to, but is
properly and essentially, s/jf/s;;?, — spasm does not necessarily
exclude organic disease ; spasm is a mode of action in muscular
structures different from or beyond their natural and accustomed
mode. It is in itself a thing essentially vital and has no neces-
sary alliance with material conditions. It may be and often is
altogether independent of organic disease. But organic dis-
ease may be and often is instrumental in producing it.

We seem here to be touching on the truth. Let us search
a little farther in the same direction, and perhaps we shall find
it. The paroxysm of angina pectoris is plainly a compound of
pain and of something else. Of the pain there can be no
doubt. But there needs must be something more than the pain
to account for the dying feeling which attends ever}^ paroxysm,
and for actual death in a paroxysm at last.

" Spasm," it has been said, "is a mode of action in muscidar
structures different from, or beyond, the natural and accustomed
mode." The natural actions in all muscles, voluntary and
involuntary, are unaccompanied by any conscious sensation
whatever. But spasm is always accompanied with pain. And
pain and spasm, wherever they are, disable the parts which
they befall. Colic stops the peristaltic movements of the
bowels. Cramp forbids the hands to handle and the feet to walk.
But the heart is a muscle, and its functions flow from its
attributes as a muscle. Now we are in search of something in
the heart which, as the concomitant of pain, may be disabling

* 1. Primo, suLito accedit et recedit,

2. Deinde, longas liabet et integras remissiones.

3. Turn, non conteiunendam opem prajbent vinum et potioiies mera-
ciores et opium.

4. Turn, perturbatione animi augetur.

5. Turn, ivxultos annos molesta est sine alio valetudinis detrimento.

G. Turn, principio non excitatur vectione in curru ant in erpio, ut fieri
solet ubi scirrhus aut infiamniatio est.

7. Turn, in ipsa accessione pulsus non concitatur.

8. Postremo, nonnullos adoritur post primuni sonini tompus ; (luod in
morbis ex distensione Irequens est.

LECT. XXXVII.] ANGINA PECTORIS. 461

to its natural functions, and capable, according to its degree, of
hindering or abolishing them altogether. This we find in
spasm. In its spasm of smaller degree the heart fails to close
freely upon the blood and to impel it freely into the arteries.
In its spasm of greater degree it fails to project it altogether.

Herein we discern an adequate explanation of the chief
phenomena of angina pectoris. It is a spasm of the heart.

Review then the circwmtances which have been recorded in
connection with this disease. Many and various, perplexing
and seemingly contradictory, indeed they were. But now they
must begin to appear signally illustrative of its nature.

From what we know of pain and spasm, and the things
causing and pertaining to them, in other parts of the body, we
might be prepared for the same sort of things causing, and
pertaining to, them when they belong to the heart. Thus we
might expect to find angina pectoris incident to any form of
organic disease of the heart, but constant to none. And such
is the fact. We might expect to find angina pectoris where
there was no organic disease of the heart itself, but such
organic disease elsewhere as might injuriously interfere with
the functions of the heart. And such is the fact. And finally
we might expect to find angina pectoris, where there was no
detectable organic disease either of the heart or of other parts,
but where itself (namely spasm) constituted the whole disease ;
a disease purely vital, a disease of feeling and function alone,
operating by and through sound structure, it may be fatally,
always perilously. And such is the fact.*

I wish to add a few remarks iipon certain mysterious cases
of sudden death.

In a previous lecture I noted it among the hindrances of
medical experience retarding Its growth to perfection, that our
observation was largely taken up with mere fragments of cases
which do not in themselves contain enough to explain their
own nature ; and I observed moreover that " a single entire
case often furnished the key to many fragments of cases. "f

Many cases of sudden death often present themselves as
mere fragments to our observation. Individuals are found

* The fact is not within my own experience ; but I must admit what is
credibly reported,
t Pa^e 346.

462 CLINICAL MEDICINE. [lECT. XXXVII.

dead. The mode of their dissolution and the circumstances
just preceding it are unknown. And dissection after death
does not clear up their mystery. Now some such cases have their
nature explained by the very cases of angina pectoris before de-
scribed, and are shown to hold a pathological kindred with them.
R. P. was about fifty-five years of age. He had filled a
high judicial office in India, and when his stated period of
service had expired, he returned home with unimpaired health.
Ten years had wrought little change in his person, except that,
from having been thin and muscular, he was slightly tending
to fat and corpulency.

He had now been more than a twelvemonth in England,
and had taken up his residence in Hampshire, and was in the
enjoyment of his wonted health, when one day, after a
morning's shooting without any extraordinary fatigue or
exertion, he felt at dinner an unusual pain in the region of his
heart. The j)ain was not extreme, but enough to make him
leave the table and retire into his library. Warm applications
were made to the chest, and the pain soon ceased altogether.
He then begged that he might be left alone to repose until tea-
time. In less than an hour his wife returned into the room,
and found him lying upon the sofa just in the position she had
left him. She believed him asleep, but found him dead.

The examination of his body, as it was reported to me, , dis-
closed nothing that could account for his death, but a thin fat
heart ; fat was deposited upon it at the expense of its mu scular
substance. Here the very manner of the patient's dissolution
was not witnessed. The symptom last observed was pain
immediately referable to the region of the heart ; but it was
not of an extreme amount : probably it returned in a more
severe degree at the time of dissolution.

Now this case may be fairly interpreted by the case last
described, in which there was a complete observation of all that
vitalhj constituted the disease. There all was comprised in
pain ; pain occurring under the conditions which bespeak spasm,
and that of the heart. Here too all that was observed was
pain ; and it is likely that what was not observed was still
nothing else but pain, and that it directly proceeded from
spasm of the heart, and that the patient died in the first
paroxysm of angina pectoris.

LECT. XXXVII.] ANGINA PECTORIS. 463

P. W. M. was sevcnty-tlirco years of age. The whole
course of his life had been singularly exempt from illness. For
many years he had been employed in a regular routine of
duties belonging to a government department. In the course
of the few last years he had consulted me three or four times
for slight complaints of the stomach, and thus gave me the
opportunity of learning that his pulse was habitually very
small and very feeble. One winter, when bronchial catarrh
was very prevalent, he did not escape the general malady. He
was not very ill, but ill enough to make it prudent for him to
keep his bed for three or four days, and then for a few days
more not to return to business. In little more than a week he
was so nearly well that I discontinued my attendance. The
last day I saw him he made light of his past illness and ridi-
culed the care which had been taken of him. At night he
retired to rest apparently well, and the next morning was
found dead in his bed, and cold. On examination after death
nothing notably wrong was found within the brain, nothing
within the lungs, nothing within the pleur.ne. The bronchi, to
which the symptoms of his past illness belonged, presented
nothing remarkable. But the heart was very small in all its
dimensions, its muscular substance altogether very thin and
very soft without being fat, and both its coronary arteries , as
far as they could be traced, were mere bony tubes.

Here the symptoms immediately preceding dissolution were
unobserved. It is probable that he died of a first paroxysm of
angina pectoris, of a first spasm of the heart.

I was curious to learn whether this gentleman had ever in
his life been known to suffer anything approaching to angina
pectoris. But I could not find that he had. There was how-
ever one remarkable circumstance about him which was pro-
bably connected with the feeble structure of his heart. He was
strangely averse from bodily exercise. His residence was in
the neighbourhood of Russell Square, and his business in the
City. But he never would walk to his office if he could help
it. When he was in the country he would be in the open air
from morning to night, but never on foot, always on his pony.
In all this he might have been unconsciously favouring his
feeble heart.

464

CLINICAL MEDICINE. [lECT. XXXVIII.

LECTUEE XXXVIII.

ANGINA PECTORIS CONTINUED. ITS CLINICAL HISTORY AND

TREATMENT. CONDITIONS TO BE NOTED IN THE INTERVALS

OF ITS PAROXYSMS. PARALLEL BETWEEN IT AND EPILEPSY

RESPECTING THEIR TREATMENT. MANAGEMENT OF THE

PAROXYSM. W^HAT AUSCULTATION TEACHES. WHAT THE

VARIOUS CIRCUMSTANCES OF ITS CLINICAL HISTORY.

The cases already given offer a striking representation of
angina pectoris in what concerns the paroxysm, displaying its
essential conditions and its fatal tendency. But they are extra-
ordinary cases. And extraordinary cases are often merely
curious, and interesting only because they are curious. But
sometimes they are interesting, because they furnish rare and
fortunate opportunities of instruction, filling up gaj^s in our
knowledge, or fortifying it with new proofs, and so giving it a
higher degree of certainty than it had before. Thus the cases
which have been recited seem to carry us a little beyond our
former knowledge of angina pectoris.

In the last lecture it was almost taken for granted that the
assemblage of symptoms constituting angina pectoris was to be
found by turns in connection with all forms of unsoundness
which belong to the heart. The fact, you may perhaps think,
should rather have been verified by an appeal to numerous
cases and dissections, especially since it was a good deal relied
upon as a basis of our reasoning. But this would have been a
long business. Let it then be enough for me now to refer you
to a source, where this very fact is authenticated, and where
indeed the whole learning of our present subject is set forth
with admirable accuracy and comprehensiveness.*

My purpose however is to take what I have myself seen,
and to comment upon it as I would upon cases in the hospital.
Have I then any thing more to say of the mere paroxysm of

* Encyclop. of Practical Medicine, Art. Angina Pectoris, by John
Forbes, M.D.

LECT. XXXVIII.] ANGINA PECTORIS. 465

angina pectoris ? Thus much only ; 1st, that in different
individuals and in the same individuals at dilibrent times the
period of its duration is apt to vary. It may come and go and
be all over in a minute. Or it may last many minutes, oven a
quarter of an hour. Or it may be protracted for half an hour
or an hour. 2ndly, that the two elements (so to speak) of which
the paroxysm consists, arc apt to vary proportionably to each
other. The pain and the dying sensation may be equal in degree,
and both may be extreme. Or in different individuals and in
the same individuals at different times the one may exceed the
other. The dying sensation, however, I have more frequently
found to surpass the pain than the pain the dying sensation.

Nothing more need be said of the paroxysm in the way of
description at least.

But is not angina pectoris a disease altogether of paroxysms ;
and when we have learnt what the paroxysm is, have we not
learnt everything ? Why, no ! There still remains its clinical
history and all the circumstances prior, predisposing and con-
ducive to it ; and these, when we come to its treatment, must
engage our attention more, far more, than the paroxysm itself.

For only let us consider, and we shall find this to be the
common condition of almost all diseases which consist in dis-
tinct and separate paroxysms, namely, that their treatment,
whether it aim at postponement or mitigation or absolute cure,
is occupied not with the paroxysms themselves but with cir-
cumstances which appear in the intervals between them. Take
epilepsy for example. In the attack itself our chief care is to
protect the patient from injury. I do not know that we either
can, or pretend to, do any thing for the mere convulsions. It
is when the convulsions are over that we seek for indications to
guide our remedies, and that we betake ourselves to the proper
business of medical treatment. It is then, that we watch the
brain in its habitual and daily operations both mental and
physical; and that we watch too all those organs especially
with which the brain holds a more obvious relation of function
and sympathy, the heart, the kidneys, the stomach and bowels,
and learn whether all is right, or what is wrong, with them.
It is then, that we note well the habitual state of the vascular
system, whether it be plethoric or anaemic, and of the nervous
system, whether it be torpid or excitable. We seek in all these

30

466 CLINICAL MEDICINE. [lECT. XXXVIII.

organs and systems of organs for actions or sufferings which,
may be more or less, nearly or remotely, conducive to the
epileptic paroxysm ; and wherever we find them we minister
to them. Moreover we are, above all, inquisitive after any
notable circumstance, within or without the body, immediately
preceding the paroxysm, which can have force to call it forth.

Thus we address ourselves to the treatment of epilepsy.
And we address ourselves to the treatment of angina pectoris
in like manner.

As to the attack itself of angina pectoris, it is very much
more an affair of life and death than is the attack of epilepsy,
and so there is more room and more need for our inter-
ference with it. But for what purpose is our interference?
For the purpose rather of saving life than of treating the
disease. For say that we do save the patient's life in the
paroxysm of angina pectoris, (a great thing truly to be able to
say,) yet when his paroxysm is over, it is not at all less likely
to return because we have saved his life for the time being.

The paroxysm indeed has its proper management, which
must be considered ; but the real treatment of angina pectoris,
whether it look to mitigation or postponement, or even con-
template the possibility of cure, concerns itself with things
which are to be ascertained leisurely in the intervals between
the attacks.

As in epilepsy, so in angina pectoris, we first inquire into
the habitual state, as to function and structure, of that organ
from which the paroxysm, when it arrives, directly proceeds.
We now seek to know all we can about the heart, as we then
did about the brain ; and next all we can about the blood-
vessels immediately springing from the heart : and then about
the whole vascular system, whether it be plethoric or anaemic ;
and then about the nervous system, whether it be torpid or ex-
citable. And the stomach and bowels and their subservient
viscera we scrupulously watch. And lastly in angina pectoris,
even more than in epilepsy, and more than in any disease of
paroxysms, we desire to come at a sure knowledge of the con-
ditions, which in each particular case are apt to call forth the
attack, whether they proceed from the body or the mind, or
from meats and drinks, from within or without, from things
that can be avoided or things that cannot.

LECT. XXXVIII.] ANGINA PECTORIS. 467

Here then, is the whole subject put in working form and
order. Lot us see what we can make of it, when we come to
apply our remedies.

First for the paroxysm itself. Now the truth is, we seldom
witness the paroxysm. We are summoned ; but it has passed
away before we arrive, except in some instances of its unusually
long duration and great severity. Indeed the patient has
almost always either to treat it for himself or trust to whoever
may be at hand to help him. The patient then, that is, the
person who has once suffered an attack of angina pectoris and
is almost sure to suffer it again, the patient himself and those
about him must be instructed how to be prepared for it and
what to do when it arrives.

The two constituent elements of the paroxysm, the sense of
dissolution and the pain, have each their appropriate remedy.

The sense of dissolution calls for those stimulants which take
effect in the quickest way, for aether and ammonia, -^ther can
fetch up life from a deeper prostration than all other stimulants,
and therefore it is to be chosen in the greatest extremity.
Hoffmann's aether and spiritus ammonia} should always be
within the patient's reach, and, when the attack comes on, a
teaspoonful of one or the other or of both together should be
given, just so much diluted with water as will allow them to be
swallowed. If the paroxysm do not cease the remedy must be
repeated in a few minutes. If it cease and return, the remedy
must equally be repeated. And so on again and again, while
the threatening of dissolution continues, or while it is going
and returning. There is no need of being more explicit. The
emergency indeed is great, but its management is plain enough.
The simple purpose is to keep life going until the paroxysm
is over.

But the other element of the paroxysm, the pain, has, it
was said, its appropriate remedy. True ; but before its appro-
priate remedy has time to reach it, the paroxysm and its pain
are commonly both gone away together. "When however the
paroxysm is protracted for a quarter of an hour, or for half an
hour, or for a whole hour and more, or when it goes and comes
again at brief intervals, then its sharp agonising pain, con-
tinuous or recurring, is to be treated as iiain. And then any
other remedy is utterly useless but opium. There is a strength

468 CLINICAL MEDICINE. [lECT. XXXVIII.

and a prevalency in tlie pain of angina pectoris whicli nothing
but opium has the power to master. A drachm of laudanum
must be given with the sether ; and given again in a quarter of
an hour, if it have made no impression on the pain ; and yet
again in another quarter of an hour, if the pain have not yet
ceased, or have ceased and returned in all its strength.

And now, when the paroxysm, be it of more or less peril,
of longer or shorter duration, treated by us or treated by the
patient himself, is past and gone for the present, our task as
physicians is only beginning. For now we must proceed to learn
why it ever took place at all, and provide, if possible, that it
never shall take place again, or that it shall be mitigated or
postponed.

Having witnessed such a formidable assemblage of symp-
toms, and knowing that they spring from the heart, we betake
ourselves at once in every instance to inquire into its condition.
We are indeed well aware of the conclusion, justly drawn from
a summary of results furnished by numerous cases, that there
is no certain form of disease or disorganisation of the heart to
which angina pectoris necessarily belongs, but that it is incident
to many, if not to all. Nevertheless the form with which it is
found in alliance, must be that from which it is derived, in each
particular instance. Therefore in each particular instance we
should seek to learn what it is ; to learn, I mean, during life, so
far as by its sounds, its resonances, and its impulses the heart
can declare its condition. This knowledge, which comes chiefly
from auscultation, may or may not advance our knowledge of
angina pectoris absolutely beyond the point where morbid
anatomy has left it. What it really does, we shall see pre-
sently. It may only assist our treatment of the case in hand.
But whether it do so or not, our duty is to ascertain all that is
ascertainable for the chance of good which may come, from our
more perfect acquaintance with his case, to every individual
patient.

Observe, however, before we proceed further (what it is
most important to bear in mind) that in angina pectoris auscul-
tation is not applied to the diagnosis of the disease. The
disease is a certain assemblage of symptoms, and not any con-
stant pathological condition belonging to the structure of the
organ. Therefore when auscultation detects ndw this, now that,

LECT. XXXVII r.] ANGINA PECTORIS. . 469

liathologiciil condition of the heart or of the large blood-vessels
in different cases, it does not reach the disease but only circum-
stances of the disease. It does not reach its clinical diagnosis
absolutely, hut only a part, yet an important part, of its clinical
history in the individual.

Let me now take the last thirteen cases of angina pectoris
which occurred to my observation, and see what it was that I
made out, by examination of the chest, in the intervals between
the paroxysms.

In three of the thirteen cases, the prascordial region pre-
sented the usual extent of resonance to percussion ; while the
impulse of the heart was most feeble, and not to be felt in the
least degree beyond the point where its apex strikes the ribs.
Its sounds were perfectly natural in kind, but raised to their
highest intonation and diffused over the entire front of the chest,
but not conveyed along the aorta. These signs, the defective
impulse, the far spreading and excessive sound and the perfect
resonance of the prascordial region, plainly denoted some
change of structure in the heart which brings loss of power.
They implied simple atrophy and attenuation of its muscular
substance.

In other three cases, the preecordial region was altogether
dull to percussion ; and the imperfect resonance extended as far
as the right mamma. The impulse of the heart was very
feeble. Its sounds were (as it were) muffled and dull with
scarcely a perceptible distinction between the two. They were
heard all over the front of the chest and in the left axilla but
not at all in the aorta. In one of the cases the beats of the heart
were irregular ; in the other two they were rhythmical. These
signs too denoted some change of structure in the heart which
brings loss of power ; but it was not simple atrophy and attenu-
ation of its muscular substance. Such atrophy and attenuation
there might be. But the bulk of the organ was augmented
withal ; augmented however by the addition of something
which was a source of weakness ; most probably of fat. The
general habit of the patients confirmed the suspicion.

Again, in other three cases the natural sounds of the heart
were lost, and changed into (what we have called) endocardial
murmurs. These murmurs were very loud, and were heard
equally at its apex and its basis, and in all the prsecordial

470 CLINICAL MEDICINE. [lECT. XXXVIII.

region, and diffused widely over the chest in front, and con-
veyed along the aorta and the subclavian and the carotid arteries.
Thus by their kind, by their extent, and by their direction
they sufficiently declared, in all three cases, an unsoundness
both of the mitral and of the aortic valves, while by their
loudness they showed that the impediment at the orifices was
as yet but small. In one of these cases the impulse was very
feeble and defective, while the pra3cordial region was duly
resonant to percussion, showing that the heart had lost in
power, and probably lost in bulk also, by simple atrophy and
attenuation of its muscular substance. In another the impulse
was very feeble and defective, while the praicordial region was
dull to percussion in an undue extent, showing that the heart
had lost in power and gained in bulk, probably by the addition
of fat. In the third there was no sign present to denote that
the heart had imdergone any change of structure beyond un-
soundness of the valves. ,

In the four remaining cases there were unnatural murmurs,
but they appertained rather to the blood-vessels than to the
heart itself.

In one of them all that could be found was a slight systolic
roughness at the commencement of the aorta, present at all
times and heard running across the sternum to the right ; and^
during exspiration only, heard^running towards the left clavicle,
and augmented into a real bellows-murmur. Nothing different
from what is natural could be detected in the heart itself. Here
there was no sure sign of disease but in the aorta.

In another of them both sounds of the heart in the prse-
cordial region wanted something of being natural, yet fell short
of the endocardial murmur. But the murmur became distinct
and very loud above the semilunar valves, and still louder in
the course of the aorta, and was clearly audible in the subclavian
and carotid arteries of both sides. The heart beat with some
slight excess of impulse while the pra3Cordial region was duly
resonant. Here the only detectable disease was in the aorta.
Whether the heart's small excess of impulse was due to a small
hypertrophy or to an abiding irritation imparted to it by a near
impediment of the circulation cannot confidently be told.

In another of them no unnatural sound whatever was heard
in the prsecordial region, but a murmur began to be audible just

LECT. XXXVIII.] ANGINA PECTORIS. 471

opposite the semilunar valves, and became louder and louder
beneath the sternum in the direction of the right subclavian,
and it was still loud in the right carotid ; while in the left sub-
clavian^and left carotid no murmur whatever was heard. It
was distinctly diastolic and systolic by turns. "When the pulse
was irregular, as it almost constantly was, then the murmur was
diastolic ; when it was regular, as it sometimes would be for
half a minute, then the murmur, for that half minute, woidd
become systolic. The heart's impulse exceeded neither its
natural degree nor extent, but there was some undue measure
of dulness to percussion in the pra^cordial region.

In another of them a very faint endocardial murmur at a
small space near the basis of the heart became loud opposite the
origin of the aorta, and louder beneath the upper part of the
sternum, and loudest of all in the left carotid, where there was
no extraordinary impulse ; but it was scarcely audible in the
right carotid, where the impulse was excessive ; very loud in
the left brachial, where the impulse was very small, and scarcely
audible in the right brachial, where the impulse was very great.

I have preserved no record, in this last case, of the heart's
impulse within the chest, or of the resonance or didness of the
praecordial region.

- In these two last cases, the auscultatory signs denoted
rather disease of the aorta and of certain arteries springing
from it than of the heart itself ; and moreover they denoted that
it was so situated as to make a difference either in the quantity
of blood which reached the two sides of the body, or in the
force with which it circulated in each respectively.

Thus in each particular case of angina pectoris I have
sought (and thus you must seek) to come at the knowledge of
what was really wrong at the source of the circulation, if per-
haps I might be enabled to administer more appropriately and
effectually to the patient's relief. And after all I hold it but
honesty to confess that my clinical labours pushed in this direc-
tion have had no such fortunate reward. The details which
have just been given are interesting enough, and they could not
be spared. But consider what they are, and recollect Avhat has
been said in former lectures of these and the like forms of
unsoundness in the heart and in the blood-vessels respective to
their treatment. The heart that is simply attenuated and the

472 CLINICAL MEDICINE. [LECT. XXXVIII.

Heart that is fat ; unsoundness of the sigmoid valve and un-
soundness of the mitral ; of the aorta and of its branches : these
do not, you well know, ask each its own mode of treatment. In
truth they none of them admit of any treatment /or themselves,
but only for some of their effects beyond themselves.

Thus the light thrown by auscultation upon the assemblage
of symptoms constituting this disease called angina pectoris is ,
as far as it goes, just the same as that which proceeds from
morbid anatomy ; but it reaches us sooner. For auscultation
is the anticipation of morbid anatomy. The one tells us during
life what the other waits to tell us after death.

But I say " as far as it goes." True it is, that the light
from auscultation in this affection is the same as that from
morbid anatonij'', and that it reaches us sooner ; but it does not
go so far. For there are conditions, to which angina pectoris is
often annexed, incapable of being surely known until death.
Such are certain changes, both pathological and abnormal, of
the coronary arteries, disturbing or arresting the current of
blood within them.

But beyond the heart, the aorta, and its branches within
the chest, we must look to the vascular system everywhere,
when we have to do with a case of angina pectoris. And what
is it that we are likely to find there ? Surely not the first
spring of the disease, but something that may minister to the
return of the paroxysm, and which consequently may become
an indication of treatment with a view to it.

The paroxysm is often put off and its severity mitigated and
life prolonged by no means more surely than by keeping the
vascular system in a just balance between fulness and emptiness,
between rich blood and poor blood. In some constitutions,
very happily born, the balance maintains itself ; and then there
is no need. of interference on our part. In the majority it is
not exact, yet exact enough for the ordinary purjDOses of health,
but not enovigh when there is some grave infirmity to be pal-
liated and made tolerable elsewhere. A small habitual deviation
on this side or that is readily felt and resented by the heart,
when it has undergone some form of unsoundness rendering it
obnoxious to spasm.

Thus there have been cases in which ray treatment of
angina pectoris, in the intervals of the paroxysms, has chiefly

LECT. XXXVIII.] ANGINA rECTORIS. 473

turned upon reducing- the nutritious and stimulant quality of
the patient's diet, abridging his animal food, and denying him
wine and fermented drinks altogether. There was one case, and
only one, in which I was driven to draw blood even more than
once from the arm ; an tmusual and a hard necessity ! There
have been more cases, on the other hand, in which the general
habit of the patient has made me fearful of withdrawing sup-
port, and experience has shown me the need of supplying a
well-regulated amount of stimulus in the shape of wine daily.
The administration of steel in the intervals of the paroxysms
has (I have convinced myself) in some instances been instru-
mental to their postponement.

Truly a volume might be spoken upon the subject, if one
were to enter into the detail of all the indications, which the
general vascular system may oifer to the observant physician,
for the employment of remedies as a safeguard, within all
possible limits, against the attacks of this awful disease.

And truly the same may be said of the nervous system, and
how it notifies indications of treatment by its various states of
disorder ; and how it presents itself as an avenue for remedies,
which may carry a salutary impression to the heart and with-
hold it for a time from falling into spasm. Loss of sleep,
disturbed sleej), and painful irritation and troublesome wants,
such as frequent micturition, may be among the bad habits of
the patient, or they may be induced by his disease, or they may
be aggravated by it. At all events they contribute to bring on
the paroxysm more frequently and more severely. It is won-
derful what a small quantity of opium, administered dexterously
upon such indications, will sometimes do in keeping angina
pectoris from advancing to a greater degree of suffering, or in
bringing it back from a greater to a less.

The following case carries this piece of instruction with it
at least. A gentleman had for years been the subject of angina
pectoris. He called upon me occasionally. I learnt that hitherto
the paroxysm had always come on in the day, and always from
some known exciting cause. But now he told me that for two
months it had also come on in the night, and independent of
any cause which he could discover. The attack was after this
manner. He woke in the middle of the night according to his
custom, and made water. Thus far he was free from pain.

474 CLINICAL MEDICINE. [lECT. XXXVIII.

But in ten minutes afterwards lie perceived tlie pain coming on.
It soon spread all over the front of his chest and ran on rapidly
to an agony. He had taken sulphuric a)ther in the paroxysm,
which gave him present relief, and that was all. I ordered him
in addition to the aether a drachm of paregoric on his going to
bed every night, and again on his waking and before he began
to move. From that time forth, for more than three months,
the nightly paroxysm never returned. Such sometimes are the
great effects of (what are thought) the little things of medical
practice !

These conditions, which belong to the vascular system and
to the nervous system respectively, are for us physicians to
observe and to appreciate. But the patient by his own ex-
perience finds out unerringly what in himself is the immediately
exciting cause of the paroxysm of angina pectoris. Bodily
exertion is the most frequent, and the most certain. In the
vast majority of cases upon record the first paroxysm has
arisen while the man was making some strenuous effort. He
was lifting a weight, or he was walking up hill, or he was
making way against a high wind, when suddenly pain stabbed
him through the chest, and he was ready to drop down dead.
But he stopped, and instantly recovered. Both the pain and
the death-like feeling ceased at once and altogether, and he was
quite well again.

The first paroxysm of angina pectoris, though it may be an
afiair of a minute only, never failed to carry alarm to the
stoutest mind. "A little more," he says, "and I had been
dead." But weeks and months often pass, and time almost
wears out the terror of the first before the second paroxysm
arrives. But the second comes at last, and just under the same
circumstances as the first. Again a long interval will often
succeed before the third paroxysm takes place under the same
circumstances as first and second.

In a matter so fearfully interesting to himself the patient
soon wets a clear notion of cause and effect. A few such
paroxysms read him a severe lesson of instruction ; a practical
and a profitable lesson however ; for he learns the great secret
of his own treatment. He learns that there is a point of bodily
exertion which he cannot exceed with impunity, and so he
becomes perpetually on his guard to keep within it. And thus

LECT. XXXVIII.] ANGINA PECTORIS. 475

when tlic exciting cause of angina pectoris is so plain and the
motives for watchf uhiess are so strong, even as strong as the
love of life and the fear of death, and when, above all, a man's
circumstances are such as allow him to take as much care of
himself as he pleases, many years, even ten or a dozen, have
been known to elapse between the first attack and the patient's
death.

There may be something peculiar in the kind and degree of
bodily exertion which the patient can or cannot bear, as the
following case will show. T. I^. W. was a specimen of a
country gentleman which would seem to belong rather to the
past generation than the present. Field sports had been his
business, his passion and his pleasure, all he lived and all he
cared for, for forty years. He was always on horseback and
always in the open air ; and, whenever the hounds were out,
it was a lost day with him if he was not out with them. The
longest run could even yet no more hurt him than the youngest
man in the field. He was now in his sixty-fourth year, when
he considted me for an affection which he had suffered at in-
tervals for five months. It was five months ago, when walk-
ing up hill he was seized with a sudden pain at the lower part
of the sterniun and with a strange deadly sensation besides the
pain. He stopped ; and immediately he was well again, and
able to walk on. From that time forth he could never walk
up a hill or use any extraordinary exertion without a return of
the same pain and the same deadly sensation. And, finding
they never came on spontaneously, he had learnt to be very
circumspect not to exceed such bodily efforts as he could
bear. He was sure, however, that the exertion needed to pro-
duce them was becoming less and less, and he gave me this
characteristic proof of the fact. At first he could hunt as well
as ever ; and indeed so he could still, but then he must take
care not to ride " the grey mare." Even now he could gallop
any horse he had except "the grey mare." But of late "the
grey mare " had been too much for him.

Here was a man, well knowing, from what his own feelings
told him, that an excess of bodily exertion might kill him, and
ever careful to avoid it, who was yet not afraid to get on horse-
back and follow the hounds. The fact was, habit had made
him so entirely one with his horse, that all fair riding was to

476 CLINICAL MEDICINE. [lECT. XXXVIII.

him much the same thing as being rocked in an arm-chair.
It was only when he found himself upon some hard-mouthed
beast, that he found his energies really called ujDon,

It is remarkable how men, whose life is threatened by every
attack and so in perpetual jeopardy, will often continue to bear
the aspect of perfect health for years and will die at last in
some unfortunate paroxysm, before half their friends, who were
unacquainted with the secret of their malady, ever knew them,
to be ill. And thus it Avas, because angina pectoris is com-
patible with both the appearance and reality of health in the
intervals of the paroxysms, that one good man, whom I knew,
fully understanding the nature of his malady and convinced
that he might die any moment, contrived, from motives of
tenderness to their feelings, to conceal the fact from his wife
and family to the last.

Contrasted with such specimens of angina pectoris, showing
that a man may live long with this disease and live too in the
repute of health, and die of the same and bo believed to the
last (except by himself the sufferer and those who have seen him
suffer, or have otherwise known the fact) to be a sound man by
all the world ; contrasted Avith such specimens there are others
in which the paroxysms acknowledge the same exciting cause
from the beginning and in which men live long, but the}^ have
no long intervals of real or rej)uted health, and are obliged
by hard necessity to adopt the daily caution and conduct of
invalids. For they find that less and less of bodily exertion
calls forth the paroxysms ; that more things must be avoided ;
that more vigilance is needed ; that still in spite of all vigilance
the paroxysms become more and more frequent, until at length
they seem to arise either independent of any exciting cause at
all or of any that is apparent or appreciable.

But bodily exertion is not the only exciting cause of the
paroxysm. It is probably the most frequent. And well it is,
that it should be so ; for it is most within the power of the
will to measui'e and to restrain. But in the same individual
there are often more exciting causes than one. Passions and
affections of the mind are wont to show their power over the
body especially by the manner in which they influence the
heart, even the healthy heart ; rousing it to tumultuous and
irregular action and engendering pain within it. And they

LECT. XXXVIII.] ANGINA PECTORIS. 477

show the same more conspicuously by the greater force and
frequency with which they actuate the heart in its states of
disease. Be its disease what it may, and the modes of dis-
ordered action and suffering annexed to it, what they may,
the mind by its feelings and its impulses can aggravate them
and multiply them. It can do so, and often does, in angina
pectoris.

Now the will, I fear, is far less master of the mind than of
the body. A man may resolve never to move from his chair, but
he cannot resolve never to be angry. Thus many a subject of
angina pectoris, who by skilfully measuring and limiting the
movements of his body by what he can bear, has been able to
abate the frequency and severity of the paroxysms and so to
prolong his life for years, has in an unhappy moment been
surprised into anger and died at once.

And so I believe that in angina pectoris death has followed
mental excitement more frequently than bodily excitement.
The latter may indeed be the more potential cause of the
paroxysm, but the former it is more difficult to guai-d against.

Nothing can be more plain and palpable, in the nature of
an exciting cause, than are bodily efforts and mental impulses
provoking pain and cramp of the heart, when the condition of
the organ predisposes to them. Thus a fall or a blow has not
more surely been known to kill a man than has a sudden
surprise of anger or a sudden movement from his chair.

But there are causes (I mean exciting causes) more from
within and less obvious but not less real, which can make the
healthy heart flutter and palpitate, and lead the unhealthy to
any modes of action or suffering which belong to its j)resent
disease. They may lead it to angina, i.e. to pain and cramp,
and so to death ; it may be to sudden death.

Experience is ever at hand to show what a bad stomach
and bad digestive organs can do in making the heart beat
irregularly, though it be sound of structure all the while.
I have known people suffer irregular action of a sound
heart all their lives. It has been mitigated occasionally to a
great degree. It has been aggravated occasionally to a painful
amount. But it has never entirely ceased for any considerable
period, because it has arisen from a faulty digestion, which has
been at one time better and at another time worse, but has

478 CLINICAL MEDICINE. [lECT. XXXVIII.

never been remedied altogether. And experience is ever at
hand to show, when the heart is unsound of structure, that
whether the stomach and digestive organs be good or bad, they
must have abundant care bestowed upon them both by the
patient and the physician. Every case of unsound heart we
meet -with still enforces the same lesson, that the apetite must
be denied, and meats and drinks scrupulously chosen and scru-
pulously measured, and evacuations duly obtained, if we would
practice the best methods of mitigating evils which we can-
not cure.

In angina pectoris, whatever be the form of the heart's
disorganisation upon which it essentially depends, if life be
long spared, experience gradually grows upon the patient and
the physician of more and more conditions conducive to the
paroxysm. Sooner or later the one feels and the other knows
that it may be excited by the state of the stomach.

Seldom at first can it be imputed to any obvious cause but
undue bodily exertion. And seldom still for a considerable
period (perhaps for months, perhaps for years) can it be
imputed to anything beside this undue bodily exertion and
sudden or strong mental agitation. If the patient be blessed
with healthy digestive organs, and, withal, be habitually, from
choice or from principle, careful and temperate in his diet,
then, though the paroxysm continue to recur from these two
causes, it is long before any other than these can be accused of
any share in producing it.

But, be the digestive functions ever so vigorous, if the
patient be one of the unfortunate many who never knew
experimentally what strict temperance means, then a new
exciting cause of the paroxysm is soon apparent. Simple
repletion is soon found capable of bringing on an attack of
angina pectoris. And, should the digestive functions be natu-
rally feeble, and the patient be the victim of habitual and
extreme dysjjepsia, then much sooner, even almost as soon as
the malady declares itself, does the new exciting cause become
manifest, and thenceforward the paroxysm is found to proceed
as frequently from the stomach as from any other source.

Mere dyspepsia has in some rare instances been the sole
apparent cause conducing to the paroxysm •' and extreme care
in meats and drinks has postponed it so successfully and for so

LECT. XXXVIII.] ANGINA PECTORIS. 470

long- a timo as to induce a persuasion tliat the whole malady-
was notliing more than an intense sympathy of the heart with
u disordered stomach.

The late Dr. Richard Pinchard told me that his uncle, who
had suffered imquestionable angina pectoris, made out distinctly
that each attack was induced by disorder of the stomach.
Hence it became the business of his life to take care of this
organ, having before his eyes the frightful penalty he might
pay for neglect of it. And he succeeded so well that for years
and years he did. not suffer a single paroxysm. He might well
believe, as he did, that the heart was sound, and that his angina
pectoris had been an affair simply of its sympathy with the
stomach. But at length he was found dead in his library, and
on examination the heart turned out to be large and dilated,
and its coronary arteries extensively ossified.

There is yet another circumstance which deserves to be
mentioned in the clinical history of angina pectoris, namely, its
real or supposed connexion with gout. It needs but small
professional intercourse with that class of invalids which is
well off in the world, to know what a large space gout occupies
in all their speculations concerning their own personal com-
plaints. They who have once had gout themselves or have any
hereditary claim to it, are ready to see it in every thing they
suffer, small or great, ailment or disease. And indeed, when
they have such patients to deal with, medical men themselves
are apt to glide into the popular theory, and to make a great
expenditure of colchicum upon diseases which they do not well
know what to think of or how to manage.

Sober experience, however, cannot deny that there is some
truth in these notions. The question is what and how much
truth. And this question I for one will not pretend to settle.

'Now in genuine angina pectoris, I have been asked by
patients at my first interview with them, " Don't you think it
is gout ? " And some have put the question from a mere
groundless fancy, and others from something more reasonable.

One who had seen some service in the navy, and was now
an admiral, had his first attack of gout at the age of 35 ; and
for the eight following years he never suffered it again. Then
for the next thirteen years he had it very frequently and very
severely ; the attacks returning perhaps several times in the

480 CLINICAL MEDICINE. [lECT. XXXVIII.

same year. He was now in his 56th year. And in this year
he experienced his first paroxysm of angina pectoris. The
paroxysms, varying- in frequency and severity, continued to
recur for five years. But from the first paroxysm of angina
through the entire space of the five years he had had one attack
only of gout. Now, pray do not ask me to give you the reason
for all this. I have no profound piece of Pathology that will
help me to account for it from the nature of the two aflections.
Yet I think I see in the circumstances of the jDarticular case an
explanation perhaps sufficient to satisfy common sense.

From the time that the angina first appeared, the patient,
who all his days had been a generous liver, submitted implicitly
to the most exact and rigid temperance. He ever afterwards
drank :^othing but water, and ate only the lighter kinds of
animal food, and those most sparingly.

This discipline was aimed at the angina ; and it succeeded
in mitigating and postponing its paroxysm. But cure the
angina it did not ; and it was never expected to do so. But
cure the gout it certainly did, as it might naturally be expected
to do. For the very same discipline has oftentimes been
known to cure gout, where there has been neither angina nor
any other disease to supersede it, and so to claim the credit of
being its remedy.

But I have heard of gout and angina pectoris alternating
with each other in the same subject ; when there has been more
of gout, there has- been less of angina; and when more of
angina, less of gout. This is not an affair of my own observa-
tion, but I can well conceive it to have happened. It has
probably been in the cases (already alluded to and said to exist)
where the angina has been an affection purely vital, and the
heart has suffered pain and spasm, though perfectly sound of
structure. That such an angina should germinate from the
same root as gout is not unlikely. They might both spring
from some inveterate fault of the assimilating processes. As
long as this fault was unredressed, one or other or both might
continue to exist by a sort of pathological necessity: thus
whichever happened to predominate would become for the time
a natural substitute or compensation for the other, whether it
were gout for angina or angina for gout.

(A

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